This Viewpoint discusses the critical importance of continued funding for the intramural research program in the Department of Veterans Affairs.

This cohort study estimates US Department of Veterans Affairs (VA) spending for veterans dually enrolled in the VA health care system and Medicare Advantage from 2019 to 2023.

Hospitals within the Veterans Affairs (VA) health care system exhibited growing use of observation care. It is unknown how this affected VA hospital performance since observation care is not included in acute inpatient measures. To examine changes in VA hospitalization outcomes and whether it was affected by shifting acute inpatient care to observation care. Longitudinal analysis of 986,355 acute hospitalizations and observation stays in 11 states 2011 to 2017. We estimated temporal changes in 30-day mortality, 30-day readmissions, costs, and length of stay (LOS) for all hospitalizations and 6 conditions in adjusted models. Changes in mortality and readmissions were compared including and excluding observation care. A 9% drop in acute hospitalizations was offset by a 157% increase in observation stays 2011 to 2017. A 30-day mortality decreased but readmissions did not when observation stays were included (all P < .05). Mean costs increased modestly; mean LOS was unchanged. There were differences by condition. VA hospital mortality decreased; there was no change in readmissions.

The United States organ transplantation system has recently reached a historic milestone of a cumulative 1 million transplants. Despite this considerable success in providing life-saving organ transplants to patients with end organ failure, there are ample opportunities for improvement, particularly with regard to achieving equity. Recognizing this, Congress directed the National Institutes of Health to fund the National Academies of Sciences, Engineering, and Medicine in conducting a study on deceased donor organ procurement, allocation, and distribution, recommending ways to improve equity and accountability. The National Academies of Sciences, Engineering, and Medicine study committee's report, Realizing the Promise of Equity in the Organ Transplantation System , reached multiple conclusions and agreed on 14 recommendations for action that can be grouped into 3 areas: (1) achieving equity, (2) improving system performance, and (3) increasing the utilization of available organs. Here, we review overarching areas for improvement, highlighting key recommendations, and suggest implementing actions.

The Covid-19 pandemic dramatically catalyzed use of telehealth and other virtual care modalities. Now, as virtual care delivery has become more widely accepted and increasingly used as a primary mode of care delivery, clinical contact centers (CCCs) are emerging as an important venue for access to a growing array of virtual care and other services. The Veterans Affairs Health System (VHS) has found that its call centers, which were historically used to offer patients inbound telephonic communication, have provided a foundation for regional CCCs using technology to offer patients bidirectional, multichannel communication (e.g., voice, video, text, chat) that improves health care accessibility, care coordination, and patient communication. In addition, the VHS has used the CCCs to leverage resources across care settings when managing public health emergencies. In May 2020, the VHS's Office of Veterans Access to Care led an initiative to modernize and consolidate the 87 individual Veterans Affairs Medical Center (VAMC) call centers into 18 regional CCCs serving all 171 VAMCs. Although still a work in progress, the Veterans Affairs CCC initiative — branded VA Health Connect — has expanded access to primary care, pharmacy services, emergency medicine, and mental health services. VA Health Connect is now responding to more than 40 million inquiries per year, with improvements in speed to answer, abandonment rates, and first-contact resolution. The authors describe some lessons learned in the implementation of VA Health Connect about how to involve people, processes, and technology to enhance patient services. The application of human-centered design can inform technology adoption and configuration of multichannel (omnichannel) communications. Critical to the success of VA Health Connect has been the incorporation of change management, effective mechanisms for deploying care delivery technology, and the importance of standardized data for performance improvement and organizational learning.

PurposeTo examine changes in rural and urban Veterans' utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization.MethodsUsing repeated cross-sectional data of VHA enrollees' hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans' probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans' travel distances to hospitals.FindingsOver time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans' probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals.ConclusionsDespite limited access to rural hospitals, these data demonstrate an increase in rural Veterans' use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

Importance Many veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations.Objective To compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data.Design, Setting, and Participants This cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023.Exposures Treatment in VA or non-VA hospital.Main Outcome and Measures Thirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older).Results There was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age >= 65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age >= 65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age >= 65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age >= 65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age >= 65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients.Conclusions and Relevance In this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.

On June 30, 2022, the US Supreme Court issued a 6–3 decision in the case of West Virginia v Environmental Protection Agency1 (EPA) that portends poorly for US public health in two ways. First, the decision limits EPA's ability to regulate greenhouse gas (GHG) emissions from electrical power plants and thereby curtails its ability to combat the many health harms caused by the climate crisis. Second, because the decision was based largely on the major questions doctrine, it potentially undermines the ability to regulate health matters of major significance.

This cohort study examines changes in the use of Veterans Affairs (VA) and non-VA hospitals by VA enrollees and mortality associated with these policies.

This Viewpoint discusses the role that health care plays in climate change, both as a contributor to harm and as a leader in solutions, via approaches that can be implemented by US federal agencies.

There is increasing understanding, globally, that climate change and increased pollution will have a profound and mostly harmful effect on human health. This review brings together international experts to describe both the direct (such as heat waves) and indirect (such as vector-borne disease incidence) health impacts of climate change. These impacts vary depending on vulnerability (i.e., existing diseases) and the international, economic, political, and environmental context. This unique review also expands on these issues to address a third category of potential longer-term impacts on global health: famine, population dislocation, and environmental justice and education. This scholarly resource explores these issues fully, linking them to global health in urban and rural settings in developed and developing countries. The review finishes with a practical discussion of action that health professionals around the world in our field can yet take.

Australia is famous for its unique and often dangerous animal life, and especially its venomous snakes. Australia’s Dangerous Snakes provides an in-depth look into the lives of this iconic group of animals. More than 100 terrestrial and 30 marine species of venomous snakes inhabit this island continent and the waters surrounding it; these include some of the world’s most deadly serpents. The book reviews the biology, natural history, behavior, and health risks of Australian snake species that are dangerous to humans, including the production, actions, and uses of their venoms and the clinical management of their bites. Something not usually seen in books about venomous snakes and a particular strength of this book is its discussion of the essential roles these animals play in their ecosystems. After a short introduction, Chapter 2 discusses the public health significance and relative danger of snakes and snakebites. Chapters 3 through 5 then cover in much detail the morphology, identification, and distribution of the species most dangerous to humans. These 3 chapters constitute 40% of the book. Chapter 6 reviews the declining numbers of snakes and conservation efforts to combat the many existential threats facing some of these species. Chapters 7 and 8 will likely be of most interest to medically oriented readers insofar as they discuss envenomation and the various snake venoms, as well as the first response to, clinical management of, and complications of bites from these species. Although the discussion of snakebite medical management is substantive, many clinicians will want to have ready access to other clinical references when managing bites from these species, especially when managing their diverse complications. The body of the book concludes with a chapter on snake-human interactions. This is followed by an appendix on Australian antivenoms and snake handling, a glossary, a 45-page bibliography, and an index. I was disappointed that the many references are not linked to the content of the chapters, precluding the ability to easily access references supporting individual statements or data cited in the text. Australia’s Dangerous Snakes is a substantive, fact-filled, and easy-to-read book. The clear and straightforward text is robustly augmented by photographs, species distribution maps, tables, and other illustrations. The book will be equally at home on a herpetologist’s laboratory bookshelf or an outdoor adventurer’s living room coffee table. The book may be of particularly keen interest to herpetologists and other snake aficionados, but physicians, toxicologists, and other healthcare professionals who have an interest in snakebites—as well as zoo personnel, outdoor enthusiasts exploring Australia, and anyone else wanting detailed information about Australia’s dangerous snakes—will find the book to be a rich resource.

Introduction: Previous research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California. Methods: Breast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020. Results: 989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups. Conclusions: Rural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted. (C) 2021 American Journal of Preventive Medicine. Published by Elsevier Inc.