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OBJECTIVE: To examine primary care (PC) team members' characteristics associated with video use at the Veterans Health Administration (VA). METHODS: VA electronic data were used to identify PC team characteristics associated with any video-based PC visit, during the three-year study period (3/15/2019-3/15/2022). Multilevel mixed-effects logistic regression models on repeated yearly observations were used, adjusting for patient- and healthcare system-level characteristics, and study year. We included five PC team categories: 1.PC providers (PCP), which includes physicians, nurse practitioners, physician assistants, 2.Nurses (RN/LVN/LPN/other nurses), 3.Mental health (MH) specialists, 4.Social workers (SW), and 5.Clinical pharmacists (PharmD). POPULATION: 54,494 PC care team members nationwide (61,728,154 PC visits; 4,916,960 patients), including 14,422 PCPs, 30,273 nurses, 2,721 MH specialists, 4,065 SWs, and 3,013 PharmDs. RESULTS: The mean age was 46.1(SD = 11.3) years; 77.1% were women. Percent of video use among PC team members varied from 24 to 84%. In fully adjusted models, older clinicians were more likely to use video compared to the youngest age group (18-29 years old) (example: 50-59 age group: OR = 1.12,95%CI:1.07-1.18). Women were more likely to use video (OR = 1.18, 95%CI:1.14-1.22) compared to men. MH specialists (OR = 7.87,95%CI:7.32-8.46), PharmDs (OR = 1.16,95%CI:1.09-1.25), and SWs (OR = 1.51,95%CI:1.41-1.61) were more likely, whereas nurses (OR = 0.65,95%CI:0.62-0.67) were less likely to use video compared to PCPs. CONCLUSIONS: This study highlights more video use among MH specialists, SWs, and PharmDs, and less video use among nurses compared to PCPs. Older and women clinicians, regardless of their role, used more video. This study helps to inform the care coordination of video-based delivery among interdisciplinary PC team members.

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BACKGROUND: Few large sample studies have examined whether disparities, as measured by the proxy of race/ethnicity, are observed in long-term mortality after high-risk operations performed in a United States national health system. We compared operation year-related mortality risk by race/ethnicity after high-risk operative interventions among patients receiving care within the VHA. METHODS: From the Veterans Affairs Corporate Data Warehouse and Surgical Quality Improvement Program, data were retrieved for 426,695 patients undergoing high-risk surgical procedures in non-cardiac, general, vascular, thoracic, orthopedic, neurosurgery, and genitourinary specialties between 2000 and 2018. Operation year was used as a surrogate measure of advances in technology and perioperative management. Underrepresented race/ethnicity groups were compared in a binary form with Caucasian/White race, as the reference category. The primary outcome was time to mortality, defined as death occurring at any time, due to any cause, during follow up, and after the initial, eligible surgery. RESULTS: The median follow-up after 537,448 operations among 426,695 patients was 4.8 years. After adjustment for preoperative risk factors and demographics, long-term mortality risk decreased significantly to a hazard ratio of 0.96 (95% confidence interval, 0.962 to 0.964) over calendar time. Long-term mortality was not significantly higher among African Americans/Blacks compared to Caucasians/Whites (p = 0.22). Among Hispanics, differences in mortality risk favored Caucasians/Whites in the early years under study-a difference that dissipated as time progressed. In the most recent years, no difference in mortality was observed among Asian/Native Americans and Caucasians/Whites. CONCLUSIONS: Risk-adjusted long-term mortality after high-risk operations among Veterans Affairs hospitals did not significantly vary between African Americans/Blacks, Hispanics, and Asian/Native Americans groups.

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DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Utilization of clinical pharmacists providing comprehensive medication management (CMM) has been shown to improve the quadruple aim of healthcare. Lack of fidelity surrounding CMM practice standardization components has led to heterogeneity in interpretation of clinical pharmacist outcomes. We compared 2 Veterans Health Administration (VHA) facilities with the patient-aligned care team (PACT) Platinum Practice designation in terms of clinical pharmacist practitioner (CPP) access and care quality relative to national CPP averages. METHODS: All data was extracted from the VHA Corporate Data Warehouse (CDW) and reports derived from data within the CDW. Within the fiscal year 2019-2020 timeframe, the PACT Platinum Practice facilities were assessed against a national average comparator on quality and access metrics using electronic VHA databases that capture data on patient visits with a CPP. For the evaluation of care quality, an electronic composite score of diabetes and hypertension metrics was used. Third next available appointment for the primary care provider (PCP) and CPP utilization were used as measures of access. RESULTS: Compared to national averages, the PACT Platinum Practice facilities had a higher proportion of patients meeting the evaluated quality metric across all months of the study period. For access, the mean time to the third next available primary care appointment was lower for the PACT Platinum Practice facilities compared to the national average. PACT Platinum sites had CPP utilization rates higher than national averages across the study period, and these rates remained stable. CONCLUSION: This study demonstrated improved quality and access outcomes for 2 VA medical centers designated as PACT Platinum Practice sites relative to national averages. This is important because these practices have been evaluated and shown to have fidelity with the CMM practice management component. Evaluation of outcomes removing the element of practice heterogeneity allows for a more standardized comparison of outcome measures.

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Background: Age is a strong prognostic factor in acute lymphocytic leukemia (ALL), with children doing better than adults with the same disease. One hypothesis for this age-based disparity is differences in treatment regimens. Optimizing care for adolescents and young adults (AYA) with ALL has not been well defined and disparities in care exist. We conducted a retrospective study of all veterans with ALL diagnosed between the ages of 18 and 45 since the year 2000 to evaluate disparities among prognostication methods, treatment regimens, and accrual to clinical trials with regard to age and race/ethnicity and how these factors influence overall survival. Methods: Electronic medical record data from the VA Informatics and Computing Infrastructure (VINCI) were used to identify 6,724 patients with an ICD-9 or 10 code for ALL. All patients were chart checked to confirm an ALL diagnosis between the ages of 18 and 45 and excluded if they were diagnosed before 2000, had childhood ALL, or if induction protocol was not recorded. A total of 252 patients were included in the final analysis. Multivariate analysis was performed with controls for age, ALL subtype (B, T, mixed phenotype), Ph status, cytogenetic risk (based on modified Medical Research Council-Eastern Cooperative Oncology Group (MRC-ECOG) study), obesity (body mass index (BMI) > 30), and race. Results: Patients treated with pediatric regimens, including pediatric-inspired regimens, have statistically significant (P = 0.009) survival gains, with a hazard ratio (HR) of 0.52 after controlling for age, obesity, ALL subtype, cytogenetic risk and race. White patients had significantly improved OS compared to people of color (HR 0.57, P = 0.02) after controlling for the aforementioned covariates. Black patients were far less likely (23%) to receive a transplant than non-Black patients (46%). Only 7% of patients were treated on a clinical trial. Conclusions: These data demonstrate that treatment with a pediatric regimen significantly improves overall survival in patients up to the age of 45 and suggests ongoing shortcomings in treatment for young adults with ALL, especially 30 to 45 years old, including persistently high use of adult induction regimens, low rates of referral to clinical trials, and significant racial disparities in bone marrow transplants for Black patients.

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Background: In the United States, diabetic kidney disease (DKD) affects about one-third of individuals with type 2 diabetes, causing significant economic burdens on the health care system and affecting patients' quality of life. Objective: The aim of the study was to quantify the burden of care in patients at different stages of DKD and to monitor shifts in healthcare costs throughout these stages. Methods: This study used data from the Veterans Affairs National database, focusing on US veterans diagnosed with DKD between January 2016 and March 2022. Aggregated all-cause health care costs per month were summarized using descriptive statistics. We used a generalized linear model to calculate the cost of DKD patent care based on the stages, dialysis phase, and kidney replacement therapy. Results: The cohort of 685,288 patients with DKD was predominantly male (96.51%), White (74.42%), and non-Hispanic (93.54%). The mean (SD) per-patient per-month costs were $1,597 ($3,178), $1,772 ($4,269), $2,857 ($13,072), $3,722 ($12,134), $5,505 ($14,639), and $6,999 ($16,901) for stages 1, 2, 3a, 3b, 4 and 5 respectively. The average monthly expenditure for patients receiving long-term dialysis was $12,299. Costs peaked sharply during the first month of kidney replacement therapy at $38,359 but subsequently decreased to $6,636 after 1 year. Conclusions: The economic implications of DKD are profound, emphasizing the need for efficient early detection and disease management strategies. Preventing patients from progressing to advanced DKD stage will minimize the economic repercussions of DKD and will assist health care systems in optimizing resource allocation.

Diabetic kidney disease (DKD) places a substantial burden on health care systems in the United States. In part of our effort to close the knowledge gap around the disease burden, care cost analysis for the patients with DKD was performed for US veterans. Along with stage progression, overall care costs per-patient per-month drastically increases from $1,597 (stage 1) to $6,999 (stage 5). Monthly costs exceeded $10,000 once veterans started to receive long-term dialysis. The quantitative summary will help health care systems efficiently allocate resources across various disease sectors.

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BACKGROUND: Studies show interdisciplinary treatment is highly effective for addressing chronic pain syndromes, including headache disorders. Increasingly, advanced practice pharmacists work collaboratively with physicians to apply their unique skills to enhance patient outcomes. OBJECTIVE: This qualitative study aimed to elucidate the potential in the Veterans Health Administration (VHA) for increased roles of clinical pharmacist practitioners (CPPs)-advanced practice pharmacists with a scope of practice-in collaborative, interdisciplinary headache care teams. Our research question was: How do CPPs integrate with interdisciplinary headache care teams in Headache Centers of Excellence (HCoE) and non-HCoE VHA facilities, and how can their roles be configured to optimize headache specialty care services? METHODS: This cross-sectional qualitative study used purposive sampling to recruit CPPs providing headache care within HCoEs and in non-HCoE VHA facilities for virtual, recorded, individual interviews. Multi-stage qualitative data analysis entailed: team discussions; immersion/crystallization for close reading of transcripts to identify emerging patterns of HCoE/non-HCoE comparison of CPPs' experiences; team data sorting using spreadsheets; and further immersion into sorted data for final identification of comparisons and interpretation of the data. RESULTS: A total of 15 CPPs involved in headache care were interviewed, with about half working in HCoEs and half in non-HCoE VHA facilities across the United States. CPPs' roles within and outside HCoEs have considerable overlap as both groups co-manage patients with headache with physicians. CPPs have independent and collaborative responsibilities as they extend headache specialists' services by providing direct patient care and referring to additional providers for headache treatment. When their roles differ within and outside HCoEs it is largely due to level of integration on interdisciplinary headache or pain teams. CPPs in HCoEs collaborate with headache neurologists and interdisciplinary teams; some outside HCoEs do as well, while others work with primary care. CPPs' weekly time dedicated specifically to headache tends to be greater in HCoEs. Nevertheless, most interviewees in both groups stated patient need exceeds CPP availability at their facilities for conducting detailed chart reviews, initial visits to understand the context of patients' headache, and scheduled follow-ups over time to monitor and adjust treatment. CPPs also consult with and educate physicians on headache pharmacy, particularly regarding appropriate use of non-formulary medications. CONCLUSION: Findings from this study suggest that CPPs' roles in headache care are valuable to clinical colleagues and their patients and should be leveraged and expanded within HCoEs and non-HCoE VHA facilities. When substantively integrated into interdisciplinary headache care teams, CPPs offer unique knowledge, headache management and patient behavior change skills, extend headache specialists' services, and provide both patient and physician education. These combined responsibilities contribute to enhancing patient outcomes and facilitating ongoing access to high quality, evidence-based headache care.

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AIM: To examine nurse workplace bullying relative to diverse sexual orientation and gender identity groups. DESIGN: Observational cross-sectional study. METHODS: Using an annual organisational satisfaction survey from 2022, we identified free-text comments provided by nurses (N = 25,337). We identified and themed comments for specific bullying content among unique respondents (n = 1432). We also examined close-ended questions that captured organisational constructs, such as job satisfaction and burnout. We looked at differences by comparing diverse sexual orientation and gender identity groups to the majority using both qualitative and quantitative data. RESULTS: For the free-text comments, themed categories reflected the type of bullying, the perpetrator and perceived impact. Disrespect was the most frequent theme with supervisors being the primary perpetrator. The reported bullying themes and workplace perceptions differed between nurses in the diverse gender identity and sexual orientation group compared to other groups. Nurses who reported bullying also reported higher turnover intent, burnout, lower workplace civility, more dissatisfaction and lower self-authenticity. CONCLUSION: Diverse sexual orientation and gender identity groups are understudied in the nurse bullying research, likely because of sensitivities around identification. Our design enabled anonymous assessment of these groups. We suggest practices to help alleviate and mitigate the prevalence of bullying in nursing. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. IMPACT: We examined differences in perceptions of nurse bullying between diverse sexual orientation and gender identity groups compared to majority groups. Group differences were found both for thematic qualitative content and workplace experience ratings with members of minority groups reporting less favourable workplace experiences. Nurse leaders and staff can benefit from learning about best practices to eliminate bullying among this population. REPORTING METHOD: STROBE guidelines for cross-sectional observational studies.

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BACKGROUND: Mucormycosis is a rare but critical infection. Due to its rarity, there is scarce evidence about the longitudinal changes in the epidemiology of mucormycosis in the US. OBJECTIVES: We investigated the longitudinal epidemiology, detailed clinical characteristics, treatment and outcomes of patients with mucormycosis within the US Veterans Health Administration (VHA) over 20-year period. PATIENTS/METHODS: All adult patients who were admitted to an acute-care hospital with a diagnosis of mucormycosis within the VHA from January 2003 to December 2022. RESULTS: Our study included 201 patients from 68 hospitals. Incidence rates of mucormycosis increased from 1.9 per 100,000 hospitalisations in 2003 to 3.3 per 100,000 hospitalisations in 2022, with a peak incidence at 5.9 per 100,000 hospitalisations in 2021, when the Delta wave of COVID-19 hit the US. Rhino-orbital (37.3%) and pulmonary mucormycosis (36.8%) were the most common types of infection. Diabetes mellitus (59.1%) and leukaemia (28.9%) were most common comorbidities predisposing to mucormycosis. Use of posaconazole or isavuconazole increased over time. The 90-day and 1-year mortalities were 35.3% and 49.8%, respectively. The mortality was lower in more recent years (2013-2017, 2018-2022) compared to earlier years (2003-2007). Age ≥65 (adjusted odds ratio [aOR]: 3.47, 95% CI 1.59-7.40), leukaemia as a comorbidity (aOR: 2.66, 95% CI 1.22-5.89) and central nervous system infection (aOR: 10.59, 95% CI 2.81-44.57) were significantly associated with higher 90-day mortality. CONCLUSIONS: Our longitudinal cohort study suggests the increasing incidence rates but lower mortality of mucormycosis over this 20-year period.

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BACKGROUND: A significant factor for the high prevalence of traumatic brain injury (TBI) among U.S. service members is their exposure to explosive munitions leading to blast-related TBI. Our understanding of the specific clinical effects of mild TBI having a component of blast mechanism remains limited compared to pure blunt mechanisms. OBJECTIVE: The purpose of this review is to provide a synopsis of clinical research findings on the long-term effects of blast-related mild TBI derived to date from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC). METHODS: Publications on blast-related mild TBI from LIMBIC-CENC and the LIMBIC-CENC prospective longitudinal study (PLS) cohort were reviewed and their findings summarized. Findings from the broader literature on blast-related mild TBI that evaluate similar outcomes are additionally reviewed for a perspective on the state of the literature. RESULTS: The most consistent and compelling evidence for long-term effects of blast-related TBI is for poorer psychological health, greater healthcare utilization and disability levels, neuroimaging impacts on brain structure and function, and greater headache impact on daily life. To date, evidence for chronic cognitive performance deficits from blast-related mild TBI is limited, but futher research including crucial longitudinal data is needed. CONCLUSION: Commentary is provided on: how LIMBIC-CENC findings assimilate with the broader literature; ongoing research gaps alongside future research needs and priorities; how the scientific community can utilize the LIMBIC-CENC database for independent or collaborative research; and how the evidence from the clinical research should be assimilated into clinical practice.

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BACKGROUND: Veterans have unique military risk factors and exposures during deployment that may augment their risk of post-acute sequelae of SARS-CoV-2 (PASC). The purpose of this study is to identify potential risk factors for PASC among Veterans in the national Airborne Hazards and Open Burn Pit Registry (AHOBPR). METHODS: This prospective observational study consisted of a semi-structured interview conducted via phone or videoconference from November 2021 to December 2022 among a stratified random sample of deployed Veterans nested within the national AHOBPR with laboratory-confirmed SARS-CoV-2 infection. PASC was defined as persistent new-onset symptoms lasting more than 2 months after initial SARS-CoV-2 infection. Deployment history, airborne hazards exposure and symptoms were obtained from the AHOBPR self-assessment questionnaire completed prior to SARS-CoV-2 infection (past). Post-infection symptoms and health behaviors obtained at study interview (present) were used to test the hypothesis that deployment experience and exposure increases the risk for PASC. RESULTS: From a sample of 212 Veterans, 149 (70%) met criteria for PASC with a mean age of 47 ± 8.7 years; 73 (49%) were women and 76 (51%) were men, and 129 (82.6%) continued to experience persistent symptoms of SARS-CoV-2 (596.8 ± 160.4 days since initial infection). Neither exposure to airborne hazards (OR 0.97, CI 0.92-1.03) or to burn pits (OR 1.00, CI 0.99-1.00) augmented risk for PASC. CONCLUSIONS: PASC is highly common among Veterans enrolled in the AHOBPR, but we did not observe any unique military risk factors (e.g., airborne hazards exposure) that augmented the risk of PASC. Our findings may provide guidance to clinicians in the VHA network to administer appropriate care for Veterans experiencing PASC.

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BACKGROUND: High-dose (≥24 mg) buprenorphine daily doses (BDD) may be important in treating patients with opioid use disorder (OUD) to improve retention and prevent overdose, particularly in the context of increased illicit fentanyl use. This study sought to: (1) identify trajectories for average BDD among patients initiating buprenorphine treatment for OUD and (2) assess patient characteristics associated with these identified trajectories. METHODS: Buprenorphine treatment episodes among patients in the US Veterans Healthcare Administration (VHA) from federal fiscal years 2006 to 2020 were identified. Group-based trajectory modeling (GBTM) was used to identify BDD trajectories based on weekly averages of BDD over the 180 days after buprenorphine episode initiation. RESULTS: A total of 79 303 buprenorphine treatment episodes among 44 583 patients were included in the analytic sample. GBTM identified 9 latent trajectories for BDD: (1) moderate dose, early discontinuation (10.1%), (2) moderate dose, delayed discontinuation (4.5%), (3) moderate dose, moderate-paced discontinuation (5.2%), (4) low-moderate dose, delayed discontinuation (7.0%), and (5) low-moderate dose, early discontinuation (21.1%), (6) low dose retention (9.6%), (7) low-moderate dose retention (16.7%), (8) moderate dose retention (18.6%), and (9) high dose retention (7.4%). Patient BDD can broadly be characterized as low [2-4 mg/day], low-moderate (6-8 mg/day), moderate (12-18 mg/day), and high dose (≥ 24 mg/day). Patients with episodes in the high BDD trajectory have the lowest social risk (eg, lowest rate of past-year history of homelessness) and the lowest diagnosed rate of physical and mental health-related comorbidities compared to those following other trajectories. CONCLUSIONS: BDD ranges widely and patient characteristics are significantly different between those episodes following differing BDD trajectories. Future research on the association between BDD and subsequent patient outcomes (eg, overdose) needs to carefully consider these differences in baseline characteristics.

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BACKGROUND: For decades, thousands of active-duty service members have sought treatment for trauma exposure. Stellate ganglion block (SGB) is a fast-acting nerve block documented in medical literature for nearly a century that has shown promise as a potentially life-altering treatment for post-traumatic stress (PTS). OBJECTIVE: This review aims to answer the practical questions of those who support individuals suffering from trauma: (1) SGB's safety profile (2) efficacy data (3) potential advantages and limitations, (4) a cross-cultural application example, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes. METHODS: The current body of literature, to include several large case series, meta-analyses, and a sufficiently powered randomized controlled trial, were reviewed, and presented to describe the history of SGB for emotional trauma symptoms and address the objectives of this review. RESULTS: Critical consideration is given to the safety and efficacy data on SGB and the evolution in safety-related technologies. Advantages such as decreased barriers to care, rapid onset, and decreased dropout and limitations such as treatment non-response, potential adverse effects, and misconceptions about the treatment are then described. Finally, the cross-cultural application of SGB is explored based on the deployment of SGB in Israel. CONCLUSION: SGB is associated with level 1B evidence and a reassuring safety profile. Evolving the model of care through the combined use of effective biological treatments like SGB with trauma informed talk therapy offers a hopeful path forward for supporting those who suffer from post-traumatic stress.

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Objectives: To improve healthcare access for rural cisgender women and gender diverse Veterans, we created the "Boost Team," a clinician-driven telehealth outreach service to connect this population to Veterans Health Administration (VHA) services. Methods: Between 9/2021 and 2/2022, we conducted a needs assessment in the Veterans Integrated Service Network (VISN) 21 and used those data to develop an outreach intervention. We piloted a clinician-led outreach intervention in 3/2022, and formally deployed an outreach team in 9/2022. Results: The needs assessment uncovered opportunities to educate Veterans, staff, and clinicians about available VHA women's health services, and a need for easily-accessible gender-sensitive services. During the pilot, 58% (7/12) rural cisgender women Veterans were successfully contacted, all reported positive experiences with the intervention. The formal outreach team launched in 9/2022 and consists of a nurse practitioner (NP), scheduler, Peer Support Specialist, and medical director. From 9/2022 to 12/2022 the Boost NP called 110 rural cisgender women and gender diverse Veterans and spoke to 65 (59%) of them. Common care needs identified and addressed included care coordination, new referrals, medication management, and diagnostics. Discussion: Data from Boost show that clinician-led outreach can engage rural cisgender women and gender diverse Veterans in VHA services, there is a desire for more gender-sensitive services, and there is a need for systems-level improvements to allow for improved care coordination and decreased leakage outside of VHA. Using robust strategies grounded in implementation sciences, we will continue conducting a program evaluation to study the impact of Boost and scale and expand the program.

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[This corrects the article DOI: 10.3389/fendo.2024.1086158.].

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OBJECTIVE: The objective of this analysis was to evaluate the effect of resident program training size on clinician productivity and turnover in the Veterans Health Administration (VHA), the largest education and training platform for medical professionals in the United States. DATA SOURCES: We retrieved administrative data on training programs and training facilities from the VA Office of Academic Affiliations and the VHA Corporate Data Warehouse. Data on primary care physician shortage areas were retrieved from the Health Resources and Services Administration. STUDY DESIGN: We used a quasi-experimental instrumental variables 2SLS design and constructed an exogenous predicted training allocation treatment variable as a function of the total national training program allocation. The outcome was clinical staff productivity and turnover. Secondary analyses stratified results using Health Professional Shortage Areas data (HPSA). DATA COLLECTION/EXTRACTION METHODS: Data were obtained for a national dataset of 141 VHA medical facilities and 26 specialties that hosted training programs across 11 years from 2011 to 2021 (N = 132,177). PRINCIPAL FINDINGS: Instrumental variables results showed that on average, an increase of one training slot in a specialty leads to a decrease of 0.039 visits per standardized clinic day (p < 0.001) and a 0.02 percentage point increase in turnover (p < 0.001). The direction of this association varied by specialty: while psychiatry and psychology specialties saw a decline in productivity, fields such as primary care and cardiology experienced an increase in productivity. HPSA stratified results indicate that negative effects on productivity and turnover are driven by areas with little to no primary care physician shortage, whereas shortage areas experienced a small increase in productivity and no effect on turnover. CONCLUSIONS: This quasi-experimental evaluation indicates that resident training program size is associated with reduced productivity and increased turnover in specialties such as psychiatry and in facilities with high baseline productivity. However, in specialties like primary care and cardiology, as well as areas with shortages of primary care, larger training programs are associated with increased productivity.

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BACKGROUND: Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. METHODS: We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. RESULTS: Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. DISCUSSION: Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.

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Since their inception in 1975, the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers (GRECCs) have served as incubators of innovation in geriatrics. Their contributions to the VA mission were last reviewed in 2012. Herein, we describe the continuing impact of GRECCs in research, clinical, and educational areas, focusing on the period between 2018 and 2022. GRECC research spans the continuum from bench to bedside, with a growing research portfolio notable for highly influential publications. GRECC education connects healthcare professions trainees and practicing clinicians, as well as Veterans and their caregivers, to engaging learning experiences. Clinical advancements, including age-friendly care, span the continuum of care and leverage technology to link disparate geographical sites. GRECCs are uniquely positioned to serve older adults given their alignment with the largest integrated health system in the United States and their integration with academic health centers. As such, the GRECCs honor Veterans as they age by building VA capacity to care for the increasing number of aging Veterans seeking care from VA. GRECC advancements also benefit non-VA healthcare systems, their academic affiliates, and non-Veteran older adults. GRECCs make invaluable contributions to advancing geriatric and gerontological science, training healthcare professionals, and developing innovative models of geriatric care.

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BACKGROUND/AIM: With new therapies for metastatic prostate cancer, patients are living longer, increasing the need for better understanding of the impact of comorbid disease. Prescription medications may risk-stratify patients independent of established methods, such as the Charlson Comorbidity Index (CCI) and guide treatment selection. PATIENTS AND METHODS: In a nationwide retrospective study of US Veterans, we used multivariable logistic regression and Cox proportional hazard modeling to evaluate the association between number and class of prescription medications and overall survival (OS) with age, race, body-mass index, prostate specific antigen (PSA), and Charlson comorbidities as covariates in veterans treated for de novo metastatic hormone sensitive prostate cancer (mHSPC) between 2010-2021. RESULTS: Among 8,434 Veterans, a median of nine medications and five medication classes were filled in the year prior to initial treatment with abiraterone or enzalutamide for mHSPC. Veterans on 1-4 medications had an average survival of 38 months compared to 5-9 medicines (33 months), 10-14 medicines (27 months), and 15+ medicines (22 months) (p<0.001). After adjusting for age, race, body mass index (BMI), PSA, CCI, and year of diagnosis, both the number of medications and medication classes were associated with increased mortality. The adjusted hazard ratio (aHR) [95% confidence interval (CI)] was 1.03 (1.02-1.03) for the number of medications and 1.05 (1.04-1.07) for medication classes. Medications within ATC B (blood/blood forming organs), ATC C (cardiovascular), and ATC N (nervous) were associated with worse OS, with aHRs of 1.14 (1.07, 1.21), 1.14 (1.06, 1.22), and 1.12 (1.06, 1.19), respectively. CONCLUSION: The number and class of medications were independently associated with overall survival in patients undergoing treatment for mHSPC. With new therapies for advanced prostate cancer, patients are living longer, highlighting the need for a better understanding of the impact of comorbid diseases. Simple methods to assess disease burden and prognosticate survival have the potential to guide treatment decisions.

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BACKGROUND: Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE: The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN: Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS: Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION: PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES: Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS: Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE: VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION: PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.