In the U.S’s largest integrated health system, during a 24-year period (1999–2022), bisphosphonate treatment initiation for fracture prevention in men shifted towards higher-risk populations, including older men and those with prior fracture and frailty. To evaluate 24-year trends in bisphosphonate (BP) initiation among older U.S. male Veterans and shifts in demographic and clinical characteristics of BP-treated men over time. U.S. national Veterans Health Administration (VHA) data (1999–2022) were queried to identify men aged ≥ 50 years with a first prescription for an FDA-approved BP for fracture prevention. Age, race, ethnicity, BP drug and route, prior fracture, and, in those aged ≥ 65 years, Veterans Affairs Frailty Index (VA-FI), were examined across five time periods. Temporal trends were analyzed using chi-square and nonparametric trend tests. A total of 298,340 men initiated a BP during 1999–2022, of whom 233,857 (78.4

AIMS:Urinary tract infections (UTIs) are common long-term complications in people with neurogenic bladder (NB). However, there are limited data on how UTIs impact different aspects of quality of life (QoL) in people with NB. Our objective was to understand UTI-related QoL impacts in Veterans with NB. METHODS:Twenty-three Veterans with NB and UTI diagnoses in the prior year participated in focus groups to share their perceptions of and experiences with UTIs including QoL impacts. Transcripts were coded using inductive and deductive reasoning. A patient survey was also developed using items modified from existing surveys validated for people with NB and new items generated by the study team using the focus group data. Qualitative results on QoL impacts from focus groups were integrated with the quantitative survey data to provide a more comprehensive understanding of UTI-related QoL impacts in people with NB. RESULTS:UTIs most significantly impacted daily activities, primarily by impairing mobility and restricting independence which led to more limited participation in social, family, and leisure activities. Psychological impacts were more prominent in the focus groups than the survey data. CONCLUSIONS:Results suggest that people with NB may experience substantial QoL impacts from UTIs, and patient-centered interventions may be needed to decrease the impact of UTIs.

Background: The TeleWound Practice Program (TWP) is an evidence-based, coordinated national effort to deliver technology-enabled wound care services to Veterans with chronic wounds. To inform implementation across the Veterans Health Administration (VHA), we used the Practical, Robust Implementation and Sustainability Model (PRISM) to examine Veteran and TeleWound health care provider perspectives of the TWP to identify early lessons learned.Methods: We conducted semistructured interviews informed by the PRISM with Veterans who received TWP care and TWP providers, investigating experiences with and perceptions of TeleWound care and the perceived impact of the TWP on patient outcomes. We used PRISM constructs to organize emerging themes to describe patient- and provider-level factors relevant to implementation.Results: Fifteen Veterans and seven providers participated. Both Veterans and providers reported positive experiences, to date, with the TWP and saw many tangible benefits associated with its implementation, including improved Veteran access to high-quality wound care and more efficient, convenient care with fewer costs incurred by both Veterans and the VHA health care system. Both groups suggested that preparing Veterans for TWP encounters was critical. Despite many common themes between Veterans and providers, we learned of several unmet needs and suggestions unique to the Veteran or provider experience. Veterans noted that their unique clinical needs were not always met or easily accounted for through the TWP's remote modalities, highlighting a need for technical support. Providers reported that increased administrative burden and lack of buy-in among leadership and other providers impeded implementation.Conclusion: Findings suggest that it will be essential to (1) acknowledge and build on patients' and providers' positive experiences with TWP; (2) address Veteran-level needs and suggestions, and consider individual clinical needs and preferences when deciding if TWP is the best approach for their wound care; and (3) address unmet provider-level needs (e.g., securing leadership buy-in) to support implementation.

Objective:This study aimed to examine the very long-term effects of globus pallidus interna (GPi) or subthalamic nucleus (STN) deep brain stimulation (DBS) on Parkinson's disease (PD) in a subset of patients enrolled in the CSP468 VA/NINDS prospective randomized trial. Methods:The primary outcome was the change in off-medication/on-stimulation Unified Parkinson's Disease Rating Scale III score (UPDRS III) from baseline over time between the two targets at 2, 7, and 10 years. Many secondary outcomes were also explored. Results:A total of 156 patients were enrolled in this substudy, and data were available for 68 GPi/49 STN participants at 7 years and 49 GPi/28 STN participants at 10 years. There was no overall difference in the time trend between the two targets (p < 0.09). UPDRS III improvements from baseline in the GPi cohort at 2, 7, and 10 years were 39.9% (p < 0.001), 16.4%, (p < 0.001), and 22.3%, (p = 0.10), respectively, and in the STN cohort at 2, 7, and 10 years it was 34.9% (p < 0.001), 16.9%, (p < 0.001), and 32.8%, (p < 0.001), respectively. Tremor subscores showed the greatest reduction, followed by rigidity subscores. Initial improvements in bradykinesia and axial subscores were attenuated, and UPDRS I, II, and III on-medication/on-stimulation scores significantly declined. UPDRS IV scores and motor diaries showed significant long-term improvement, and medication reductions were seen regardless of the target. At 7 and 10 years, the PDQ-39 total score no longer showed improvement, and more severe cognitive impairment was seen in both targets. Conclusion:DBS therapy has a significant beneficial effect on overall motor function, dyskinesia, and motor fluctuations over 10 years (regardless of target), though non-motor symptoms progressed. Bradykinesia, axial, and quality-of-life improvement were maintained at 2 years and then declined over time. Clinical trial registration:ClinicalTrials.gov, identifier NCT01022073, NCT00056563, NCT01076452.

INTRODUCTION:Between 1953 and 1987, the ground water at Marine Base Camp Lejeune in North Carolina was contaminated. Service members and their families living at the camp were exposed to volatile organic compounds which have been linked to several health conditions. Legislation offers reimbursement to families of service members who lived at the camp and were diagnosed with conditions related to the toxicants. MATERIALS AND METHODS:A sample of service members based at Camp Lejeune between 1975 and 1985 were surveyed and interviewed to characterize their family members' experiences with exposure-related health conditions. The survey was online, voluntary, and cross-sectional; semistructured interviews were conducted by telephone. RESULTS:A total of 1,073 surveys and 22 semistructured interviews were completed. Of the 12% who reported having a spouse on base and provided a response, 33% reported that their spouse developed an exposure-related health condition. Of the 14% who reported having a child on base, 28% reported that their child(ren) developed an exposure-related condition. The most frequently reported conditions for spouses and dependents included miscarriage and neurobehavioral effects (20.4%, 9.9%, 7.1%, and 13.0%), respectively). Qualitative data revealed that the grief of losing loved ones and coping with illnesses compounded with the financial burden of these conditions were stressors for family members. CONCLUSIONS:Service members reported that the Camp Lejeune contamination negatively impacted their family members as some developed exposure-related conditions leading to experiencing psychological and financial distress. Further research directly with family members is needed to determine the extent to which they were affected by these exposures.

Objective To conduct a needs assessment to learn about women Veterans’ needs, priorities, preferences, and experiences with mobility assistive technology (MAT). Design Cross-sectional survey study. Setting National survey. Participants Women veterans (age, ≥18y) receiving care from the Veterans Health Administration who received MAT in the last 5 years participated in an online survey (N=700). Interventions None. Main Outcome Measures The survey included questions regarding demographics, experiences with procurement, evaluation, and follow-up for MAT, and ability to participate in various activities. Results Seven hundred women veterans responded to the online survey but due to missing responses only 593 surveys were analyzed. The most commonly used MAT included canes (26%), walkers (24%), and manual or power wheelchairs (29%). Activities for which their assistive mobility device did not meet their needs included housework (26%), leisure (22%), and social activities (19%). Some women veterans identified challenges with their device related to the design and lack of options when choosing a device. Although a majority of veterans reported positive feedback in procuring their MAT, there were opportunities for improvement in follow-up. Conclusions Approximately 1 out of 5 women indicated that their devices did not meet some of their needs. The unique needs of women veterans should be considered during the design and provision of MAT, and education should be provided on maintenance of the MAT. Future research is warranted to develop possible solutions for these gaps with the goal of improving women veterans’ experiences and function related to MAT.

Introduction: Despite the growing number of women Veterans with disabilities, data on how well mobility assistive technology (MAT) meets their needs are limited. Evaluating psychosocial impact is key to ensuring that MAT not only meets physical needs but also fosters social participation, mental well-being, and independence. The aim of this study was to examine the perceived psychosocial impact of using MAT on women Veterans' competence, adaptability, and self-esteem. Methods: Women Veterans (N = 501) who received MAT from the U.S. Department of Veterans Affairs within the past five years completed a national online survey including the Psychosocial Impact of Assistive Devices Scale (PIADS). Women were asked to score the PIADS on the basis of their experiences using their primary device type: cane, leg-foot orthosis, walker, power wheelchair (PWC), scooters, manual wheelchair (MWC), or crutches. Results: Participants expressed an overall positive psychosocial impact of MAT on competence (mean = 1.03, SD = 1.23), adaptability (mean = 0.76, SD = 1.43), and self-esteem (mean = 0.67, SD = 1.22). Around 17% of the total item responses indicated a negative perceived psychosocial impact of using MAT. PWC users' item scores indicated higher positive psychosocial impact than those of other device-type users (0.001 < p < 0.023). Discussion: Despite the overall positive psychosocial benefits of MAT, use was associated with feelings of low self-esteem, frustration, and embarrassment. The results highlight a possible mental health benefit for PWC users compared with other MAT users.

BackgroundIn 2014 and 2018, respectively, Congress passed the Veterans Access, Choice, and Accountability Act (Choice Act) and the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded eligibility for and use of cross-institutional referrals among U.S. Veterans enrolled in the Veterans Health Administration.ObjectiveTo identify facilitators and barriers to patient information sharing for cross-institutional, outpatient referrals resulting from policy changes.DesignApplying the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 framework, we conducted work system and configural analyses of semi-structured interviews.ParticipantsClinical and administrative staff in six Department of Veterans Affairs (VA) facility community care liaison program offices.ApproachInterviews focused on barriers and facilitators to sharing patients' information across healthcare institutions. Transcripts were summarized by domain and coded to consensus, followed by directed content analysis and visualization using configural diagrams.Key ResultsFrom 19 interviews, we characterized a nine-step, ad hoc referral process. Barriers were reported in four of nine referral steps: scheduling, coordination, sending of pre-visit clinical records, and receipt of post-visit records. Low adoption of new technology, strained relationships with CCN clinicians, and inconsistent policies were commonly reported barriers. Largely, perceived barriers were classified as technology, people, or organization factors. The COVID-19 pandemic and a transition between third-party administrators were reported as notable environment factors.ConclusionsVA staff perceived increases in patient care delays and staff workload associated with social and technical barriers to sharing patients' information across healthcare institutions. In the cross-institutional referral process, we identified the primary configuration or combination of work system factors-technology, people, and organization- related to prevalent barriers. System-level interventions are needed to enhance relationships with clinicians across healthcare institutions, implement policies that guide patient information exchange, and design supportive technologies for efficient clinician communication during cross-institutional referrals.

This cross-sectional study evaluates trends in the utilization of and disparities in prostate magnetic resonance imaging (MRI) across the Veterans Health Administration.

Abstract Background Although recurrent urinary tract infections (UTI) are common complications in people with neurogenic bladder (NB), limited data exist on the specific ways UTIs impact quality of life (QoL) in this population. These data could help tailor patient-centered approaches to improving UTI care in people with NB. UTI Impacts on Feelings and Emotional Well-being Methods We mailed surveys to 289 Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis, or Parkinson’s Disease who had at least one in-person encounter associated with a UTI diagnosis at four Veterans Affairs Medical Centers between May 2022-May 2023. The survey was adapted from existing instruments and previously collected qualitative data. An expert panel refined the survey using a Delphi process, followed by cognitive interviews with Veterans with NB (n=8). The QoL section contained 15 survey items with 5-point Likert scale response options (higher values = greater QoL impact) which assessed how UTIs affect feelings, emotional well-being, daily activities, sex life, and social participation. To account for missing and ‘not applicable’ responses, scaled QoL scores were calculated by multiplying total survey score by the ratio of 15 / the number of items answered. Descriptive statistics summarized respondent characteristics and QoL scores. UTI Impacts on Activities Results Respondents (n=71) were older [median age (range) = 72 (36-88)], male (92%), and white (79%). Most had SCI/D (77%) and used urinary catheters (77%). 85% of respondents answered at least 13 items. Other than feeling often or always frustrated or bothered by UTIs (n=22; 31%), most respondents did not report that UTIs frequently impact feelings or emotional well-being (Figure 1). In contrast, UTIs had a strong impact on activities (Figure 2), with many respondents agreeing their UTIs have impacted diet (n=35; 50%), travel (n=37; 53%), and sex life (n=24/40 responses; 60%). Mean [standard deviation (SD)] scaled total QoL score was 40.8 (15.3) out of a possible maximum score of 75, with a mean (SD) per item score of 2.7 (1.0) out of 5. Conclusion People with NB experience substantial QoL impacts from UTIs, particularly on their daily and social activities. Patient-centered interventions focused on reducing negative impacts on QoL from UTIs are urgently needed for this population. Disclosures All Authors: No reported disclosures

Objective: The Veterans Health Administration (VHA) recently piloted the implementation of the TeleWound Practice Program (TWP), which provides interprofessional wound care to Veterans remotely. We assessed the perceptions of Veterans and healthcare team members (HCTMs), and their experiences with the TWP. Method: We surveyed Veterans from four VHA medical centres who had received at least one TWP visit between 1 May 2020 and 31 May 2021, and HCTMs associated with any TWP encounter between 1 September 2019 and 31 March 2021. Survey data were summarised using descriptive statistics and open-ended question responses were analysed using thematic coding. Results: Out of 534 Veterans approached, 194 completed the survey (a 36% response rate). Most were interested in continuing to use TeleWound care (66%), felt more motivated to participate in their wound care due to the TWP (70%), and reported reductions in travel distance (81%) and cost (81%) related to wound care. Of the 32 HCTMs approached, 19 completed the TWP survey (a 59% response rate). Respondents indicated that the TWP improved their own professional decision-making skills (82%) and supported Veterans to take a more active role in their health (100%). Challenges included insufficient training for HTCMs, lack of stakeholder buy-in, and logistical and technical issues. Suggestions for improvement related to equipment, additional training and dedicated TWP staff. Conclusion: In this study, the Veterans were satisfied with the TWP and were more motivated to engage in wound self-management after receiving care through the TWP. HCTMs also perceived the TWP as beneficial to Veterans. However, additional efforts are needed to address barriers to TWP implementation across the VHA system of care.

BACKGROUND:Urinary tract infections (UTI) are common complications in people with neurogenic bladder (NB). Limited data exist on UTI-related knowledge, experiences, and quality of life (QoL) impacts in this population. METHODS:We mailed surveys to 289 Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis, or Parkinson's Disease who had a UTI diagnosis at four Veterans Affairs Medical Centers between May 2022-May 2023. The survey was adapted from existing instruments and previously collected qualitative data and assessed patient knowledge and experiences with UTI and QoL impacts. Descriptive statistics summarized responses and scaled QoL scores were calculated, with higher scores indicating greater negative impact. RESULTS:Most respondents (n = 71) were older (mean age = 69), had SCI/D (77%), and used urinary catheters (77%). Over a third had misperceptions about antibiotic risks and the significance of a positive urine culture or bacteriuria for diagnosing UTI. 18% wanted more information about UTIs, with most preferring written materials (77%) or information at healthcare provider visits (62%). The strongest QoL impacts were on daily activities, with many respondents indicating UTIs affect diet (50%), travel (53%), and sex life (60%). Mean [standard deviation (SD)] scaled QoL score was 40.8 (15.3) out of a maximum of 75, with ≥ 3 UTIs in the prior year associated with higher scores (p = 0.02). CONCLUSIONS:People with NB may have misperceptions about UTI diagnosis and antibiotic risks, and experience substantial QoL impacts from UTIs. Provider encounters for suspected UTI may be good opportunities for delivering written education and assessing QoL impacts.

Objective: Blood pressure (BP) control reduces risk of cardiovascular disease (CVD), the major cause of disability and mortality among the nine million U.S. Veterans receiving care in Veterans Affairs (VA) medical centers. This study examined BP control, defined as a systolic BP < 130 mmHg and diastolic BP < 80 mmHg, among U.S. Veterans with hypertension at high risk for primary or secondary CVD events. Methods: We utilized data from the VA Informatics and Computing Infrastructure Corporate Data Warehouse on primary care visits within the eight Great Lakes VA medical centers for Veterans with at least one visit between January 1, 2019, and February 28, 2020 and a documented visit within the 12 months prior to study initiation date. Analyses focused on Veterans with diagnosed hypertension and one or more of the following: age ≥65 years, and/or diagnosis of CVD, diabetes mellitus (DM) or chronic kidney disease (CKD). BP control was based on the last recorded BP measurement during the study period. Results: The mean age of 83,633 Veterans with hypertension was 71.6 years (10.4) years, 96.4 % were male and race/ethnicity was reported as non-Hispanic White in 74.8 %, non-Hispanic Black or African American in 18.4 %, non-Hispanic Asian in 0.3 %, Alaskan Indian or Pacific Islander in 2.6 % and Hispanic in 2.5 %. Mean SBP and DBP based on vital signs at the last clinic visit were 130.8 mmHg (standard deviation [SD] 11.6) and 73.7 mmHg (SD 8.8), respectively. Overall, BP was controlled to < 130/80 mmHg in 38.7 % (95 % Confidence Interval [CI] 38.4, 39.1) and <140/90 mmHg in 76.9 % (95 % CI 76.7, 77.2). Among subgroups, BP was controlled to < 130/80 mmHg in 39.8 % (95 % CI 39.4, 40.2) of the Veterans aged ≥65 years, 45.3 % (95 % CI 44.7, 45.9) with CVD, 39.8 % (95 % CI 39.2, 40.3) with DM, 42.8 % (95 % CI 41.9, 43.6) with CKD and 47.1 % (95 % CI 45.5, 48.6) with CVD +DM +CKD. In contrast, BP control <140/90 mmHg was noted in over 75 % of Veterans within all subgroups. Conclusion: In this group of Veterans with hypertension and high risk for CVD events, less than half had BP controlled to < 130/80 mmHg. Future studies should investigate strategies to improve BP control such as team-based care with home BP monitoring, education of clinicians on hypertension management, and increased utilization of automated office BP.

Introduction: This study aimed to assess women Veterans' satisfaction with their primary mobility device and the related services they received. Methods: Women Veterans who received a mobility device in the past 5 years from the Veterans Health Administration (VHA) completed an online survey containing the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) about their primary mobility device. Scores were analyzed using descriptive statistics while open-ended comments were analyzed using inductive thematic analysis. Results: 571 out of 4078 (14%) invited women completed a sufficient portion (>75%) of the QUEST. They reported high levels of satisfaction with their devices and services received (>4 out of 5 indicating 'quite' to 'very' satisfied). Despite this finding around 80% of the women left comments related to discontent with their device. Main and sub-themes that were consistent across all devices included equipment issues (mechanical design, lack of features or customizability, poor quality components/material), physical and psychological impacts of the device, usability issues, and unmet service needs (lack of efficiency, lack of quality, issues with service providers and lack of access). Discussion: Women-centered design and delivery of mobility devices should be prioritized. Opportunities exist for VHA to make improvements within several areas in the service and provision process.

BACKGROUND:Community-acquired pressure injuries (CAPrIs) are common and costly among individuals living with spinal cord injury (SCI). OBJECTIVES:Describe feasibility, usability, and satisfaction of a decision support tool to prevent CAPrIs in individuals with SCI and effect of the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT) on CAPrI incidence 6 months post CAPP-FIT implementation. METHODS:Preparation for the pilot included redesigning clinic workflow and training providers using a simulation with a standardized patient. The CAPP-FIT was piloted with community-dwelling veterans with scheduled in-person and telehealth clinic visits. Processes were assessed using contextual inquiry and monthly provider meetings. Feasibility, usability, and satisfaction were assessed using the mobile application rating scale with veterans and focus groups with providers. CAPrI incidence 6 months post CAPP-FIT intervention was assessed using a propensity match of veterans who did not receive the CAPP-FIT intervention. A modified Poisson regression with difference in differences was used to estimate the incidence rate ratio of CAPrIs. RESULTS:Participants included 7 providers (3 registered nurses, 2 nurse practitioners, 2 physicians). Veteran participants (n=103) had a mean age of 64; 50% White, 33% Black; 56% with paraplegia; and 72% with incomplete injury. Veteran participants were satisfied with the CAPP-FIT, agreed questions were relevant, and improved their conversations with providers. Providers felt the CAPP-FIT was easy to use, improved communications, and promoted preventive care. Participants experienced a lower CAPrI incidence rate compared with a propensity-matched sample at the pilot site, with the decrease among CAPP FIT participants being more pronounced than among non-participants. However, the difference in difference was not statistically significant with IRR: 0.23, 95% CI: 0.048-1.066 (P=0.060). CONCLUSIONS:The CAPP-FIT seems to be a useful tool in the SCI Clinic to prevent CAPrIs in veterans with SCI, but further testing is warranted.

BACKGROUND:Between 1953 and 1987, the groundwater at Marine Base Camp Lejeune in North Carolina was contaminated with chlorinated solvents. Legislation enacted by the federal government aimed to provide disability compensation and access to health care to Veterans for conditions related to these exposures. OBJECTIVE:We assessed the impact of the Camp Lejeune-related legislation on Veterans' experiences with health care access and disability claims. MEASURE:A total of 8864 Veterans who were at Camp Lejeune between 1975 and 1985 were invited to complete an online survey about their experiences with health care and seeking compensation for conditions associated with toxicant exposure. RESULTS:Approximately 964 surveys (13%) were fully completed and analyzed. One-third of respondents reported a diagnosis of at least one associated or presumptive condition linked to toxicant exposure. Veterans who reported living/working in higher risk areas at the Camp had a 2.02 [CI: 1.41, 2.90] greater odds of being diagnosed with one of these conditions, controlling for demographic characteristics. While most Veterans accessed and were satisfied with Veterans Health Administration (VA) care, those who applied for disability compensation found the process to be unhelpful. CONCLUSION:Conditions associated with or presumptive for toxicant exposures at Camp Lejeune were frequently identified by respondents. Veterans who lived/worked in a high-risk area of the camp were twice as likely to have any of these conditions. There is a need for additional education of Veterans regarding the Camp Lejeune legislation, particularly around the disability claims filing process, and the increased risk of those who lived near the contaminated wells at Camp Lejeune.

ABSTRACT:Inappropriate urinary tract infection diagnosis in patients with neurogenic bladder may result from ambiguous symptoms experienced by these patients and contributes to antibiotic overuse. Characterization of patient-reported signs and symptoms may help providers more appropriately diagnose urinary tract infections. A previous study collected signs and symptoms recorded in electronic medical records of patients with neurogenic bladder due to spinal cord injury/disorder, multiple sclerosis, and Parkinson's disease with at least one urinary tract infection diagnosis between 2017-2018 at four medical centers. In this study, 23 veterans from this cohort with urinary tract infection diagnoses in the previous year participated in focus groups conducted May 2021-May 2022. Transcripts were coded using mixed deductive and inductive coding. Qualitative data were compared to electronic medical records data to give a comprehensive picture of signs and symptoms. Both providers and patients attributed nonspecific symptoms like urine changes to urinary tract infection, but there was discordance between patients and providers in the identification of other signs and symptoms. Several patients described providers disregarding symptoms other than fever or chills. Optimizing urinary tract infection care for patients with neurogenic bladder could involve improving patient-provider communication about urinary tract infection signs and symptoms and emphasizing thorough elicitation and evaluation of all signs and symptoms.