BACKGROUND:National surgical quality improvement programs rely on a labor-intensive process of manual data abstraction. There have been few efforts to understand stakeholders' attitudes on programmatic workflows, data collection processes, or identification of modifications to workflows that might enhance efficiency. Given contemporary data science methods, the attitudes of stakeholders regarding data collection automation could have implications for future national quality program modernization efforts. METHODS:Qualitative interviews were conducted with US Department of Veterans Affairs (VA) surgical quality nurses (SQNs) and researchers who use VA Surgical Quality Improvement (VASQIP) data from a national integrated health system. All transcripts were analyzed using thematic analysis. RESULTS:Data were obtained from 42 interviews (26 with SQNs and 16 with researchers) from 37 medical facilities across the United States. The authors found five themes pertaining to participant's attitudes regarding (1) automating data abstraction, (2) interpreting variable definitions, (3) the need for standardizing documentation, (4) factoring in human review of data collected automatically, and (5) SQNs' job security concerns. CONCLUSION:SQNs and VASQIP researchers expressed general interest and optimism about developing data science methods to automate data collection. However, participants considered human review a necessary part of data collection. More work is needed on how to automate data collection within existing surgical quality improvement programs.

BACKGROUND:The Affordable Care Act (ACA) allowed states to expand Medicaid to adults under 138 percent of the federal poverty line. Questions remain about how expansion influences health care utilization by Veterans already enrolled in the Veterans Health Administration (VHA). OBJECTIVE:To understand changes in VHA share of inpatient utilization among VHA-enrolled Veterans after Medicaid expansion. METHODS:Sample included Veterans aged 18-64 from 2011 to 2016 enrolled in VHA. Outcomes included changes in VHA share of total VHA + Medicaid inpatient days, proportion with VHA and Medicaid inpatient dual use, total per-capita inpatient days, and likelihood of any inpatient visits, moderated by VHA priority group and race. We controlled for sex, age, year, health status, ethnicity, and VHA distance. RESULTS:Population included 17,573,731 person years, 1,808,321 with inpatient days. Expansion was associated with relative decreases in VHA share of inpatient days (-2.60 percentage points [95% confidence interval -3.38 to -1.81]) and increases in proportion of VHA-enrollees using both VA and Medicaid for inpatient care (1.17 pp [0.89 to 1.43]). While both per-capita inpatient days and proportion of VHA enrollees with at least one hospitalization decreased from 2011 to 2016, no statistically significant differences existed between expansion and non-expansion states. Low-income Veterans had larger decreases in the VHA share of inpatient days (-6.27 pp [-7.32 to -5.21]) associated with Medicaid expansion. No racial groups exhibited statistically significant differences. CONCLUSIONS:Medicaid expansion is associated with reductions in VHA share and increase in dual use of VHA-Medicaid inpatient services, but no changes in overall utilization.

RATIONALE:Elevated peripheral blood monocyte counts (PBMCs) are associated with disease progression and mortality in patients with idiopathic pulmonary fibrosis (IPF). However, evidence for progression stems primarily from highly curated cohort studies or post hoc analysis of clinical trials. OBJECTIVES:We used real-world data to examine the association between PBMC and IPF mortality among a national cohort of Veterans with IPF. METHODS:We used an International Classification of Disease code-based electronic health record algorithm to identify Veterans with IPF. Those who had a PBMC available within 180 days of index IPF diagnosis were included in the analytical cohort. Mortality analyses were conducted using Cox proportional hazard models. RESULTS:We identified 30,419 Veterans with IPF and a PBMC available for analysis. Veterans with PBMC ⩾ 0.95 × 109 cells/L had a 51% higher risk of all-cause mortality (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.44-1.58; P < 0.001) in an unadjusted analysis. The risk persisted in models adjusted for age and sex (HR, 1.43; 95% CI, 1.36-1.50; P < 0.001) and after adjustment for oxygen use as a surrogate marker of disease severity (HR, 1.35; 95% CI, 1.29-1.41; P < 0.001). There was a stepwise increase in mortality risk as PBMCs increased, with a monocyte dichotomization threshold between 0.4 and 0.5 × 109 cells/L associated with HR for mortality of greater than 1.0 for both unadjusted and adjusted models. CONCLUSIONS:We found that a stepwise increase in PBMC was associated with an increased all-cause IPF mortality. A PBMC dichotomization threshold between 0.4 and 0.5 × 109 cells/L, which is lower than previously reported, was associated with an increased risk of mortality.

BACKGROUND:The COVID-19 pandemic resulted in extended disruption to the health care system. National-level data-driven comparisons of inpatient nurse staffing and workload before and during the pandemic have been limited. OBJECTIVES:Assess the extent to which registered nurse (RN) staffing and workload changed from prepandemic levels in a national integrated health care system. RESEARCH DESIGN:Longitudinal descriptive analysis. Medication pass analysis using bar code medication administration data for the peak-time medication pass (PTM) assessing year-over-year changes from 2019 to 2022. To assess significance of year-over-year changes in means we used the Welch 2-sample t test. SUBJECTS:Staff (N=42,999) administering PTM medications on Veterans Health Administration acute-care inpatient units (643 units; 127 facilities) from January 1, 2019, to December 31, 2022 (3,681,802 staff days). MEASURES:Staffing: unique staff, staff days, staff per day, patients per staff (PPS); workload: patient days, medications, medications per patient, medications per RN, PTM duration. RESULTS:RNs administered 93.6% of peak-time medications. Fewer non-RNs administered medications after the onset of the pandemic. The average number of patients per RN (PPS) in 2022 was 3.3 on medical, 3.2 on mixed medical-surgical, 3.3 on surgical, 2.5 on step down, and 1.5 on critical care units. The greatest increase in PPS from 2019 to 2022 occurred on surgical units (+0.20, P<0.0001). Across nearly all unit types and levels of PPS, medications per RN were greater and duration was longer in 2022 than in 2019. CONCLUSIONS:RN staffing and workload fluctuated widely at the onset of the pandemic. In 2022, new patterns began to emerge, showing a higher RN workload than before the pandemic.

BACKGROUND:Team-based primary care has become the norm within many large healthcare systems; however, limited guidance exists on how to optimally staff primary care teams in relationship to healthcare. OBJECTIVE:This paper examines the associations between variations in team staffing configurations on primary care access and clinical quality. DESIGN:Observational study linking national Veterans Health Administration (VHA) data from February 2020 on primary care team staffing configurations to data on access to and quality of care the teams delivered. PARTICIPANTS:We examined data from 22,390 primary care personnel assigned to 7050 teams from 1050 VA Medical Centers and Community-Based Outpatient Clinics across the USA. MAIN MEASURES:We used data from VHA's Corporate Data Warehouse. We assessed team-based measures of overall adherence to VHA's national guidelines for front-line clinical team staffing based on achievement of recommended staffing configurations in terms of quantity of staff and diversity of professional roles. To measure staffing sufficiency, we integrated total number of team members (team size) with their full-time equivalents (FTEs). To measure role diversity, we assessed deviation from guidelines using network analysis of staffing data. As outcomes, we used three measures of patient access to primary care and four measures of clinical quality that were prioritized by a prior expert panel. We analyzed associations between predictors and outcomes using random intercept multilevel models, with teams nested within healthcare facility. KEY RESULTS:Variation in team size and FTE reflected lack of adherence to VHA guidelines rather than normal variation. Overall adherence to VHA guidelines was unrelated to access or quality of care delivered. In most cases, teams with higher FTEs exhibited better outcomes. Increased role diversity was associated with decreased secure messaging communication ratios. Teams with more members exhibited improved 2-day post-hospital discharge contact, but reduced access through third next available appointments. CONCLUSIONS:Primary care teams require a minimum amount of FTE staff capacity to deliver high quality and access to healthcare. Future work should examine how these associations vary by specific job role to further optimize staffing configurations.

OBJECTIVE:To measure discrepancies in risk adjustment scores using only Medicaid or Veterans Health Administration (VA) diagnoses for Veterans dually enrolled in VA and Medicaid. STUDY SETTING AND DESIGN:Veterans aged 18-64 enrolled in the VA and Medicaid for at least one full calendar year during 2017-2020. We compared the number and overlap of annual diagnoses derived from VA and Medicaid data. We also calculated Charlson, Elixhauser, and Centers for Medicare and Medicaid Hierarchical Condition Categories Version 21 (CMS-V21) risk scores using VA-only, Medicaid-only, and combined VA-Medicaid data for each person-year. We used intraclass correlations within risk measures to compare scores across risk measures. DATA SOURCES AND ANALYTIC SAMPLE:We used data from the VA's Assistant Deputy Undersecretary for Health's (ADUSH) enrollment files regarding age and VA Priority Group to select our cohort of VA enrollees. We used T-MSIS Analytic Files (TAF) and the Demographics and Enrollment (DE) file to determine Medicaid enrollment. PRINCIPAL FINDINGS:Our study cohort contained 183,018 dual-enrollees with service-connected disabilities representing 405,318 person years and 219,977 dual enrollees without service-connected disabilities (531,948 person years). On average, service-connected individuals had 9.1 fewer diagnoses from Medicaid-only data than from VA-only data (95% Confidence Interval (CI): [9.0, 9.1]) and 5.0 fewer for non-service-connected Veterans (95% CI: [4.9, 5.1]). Intraclass correlations between VA-only data and combined VA-Medicaid scores had higher correlations for Charlson (0.816 vs. 0.591 for service connected, 0.722 vs. 0.638 for non-service connected) and Elixhauser (0.818 vs. 0.609 for service-connected, 0.723 to 0.702 non-service-connected) scores, while Medicaid-only scores had higher correlations for CMS V21 (0.756 vs. 0.666 for service-connected, 0.795 to 0.542 for non service-connected). CONCLUSIONS:Medicaid and VA data represent non-overlapping diagnoses data in three common risk scores. Researchers should consider combining records to calculate disease burden for dual-enrolled Veterans to ensure complete capture of risk.

The COVID-19 pandemic resulted in extended disruption to the health care system. National-level data-driven comparisons of inpatient nurse staffing and workload before and during the pandemic have been limited. Assess the extent to which registered nurse (RN) staffing and workload changed from prepandemic levels in a national integrated health care system. Longitudinal descriptive analysis. Medication pass analysis using bar code medication administration data for the peak-time medication pass (PTM) assessing year-over-year changes from 2019 to 2022. To assess significance of year-over-year changes in means we used the Welch 2-sample t test. Staff (N=42,999) administering PTM medications on Veterans Health Administration acute-care inpatient units (643 units; 127 facilities) from January 1, 2019, to December 31, 2022 (3,681,802 staff days). Staffing: unique staff, staff days, staff per day, patients per staff (PPS); workload: patient days, medications, medications per patient, medications per RN, PTM duration. RNs administered 93.6% of peak-time medications. Fewer non-RNs administered medications after the onset of the pandemic. The average number of patients per RN (PPS) in 2022 was 3.3 on medical, 3.2 on mixed medical-surgical, 3.3 on surgical, 2.5 on step down, and 1.5 on critical care units. The greatest increase in PPS from 2019 to 2022 occurred on surgical units (+0.20, P <0.0001). Across nearly all unit types and levels of PPS, medications per RN were greater and duration was longer in 2022 than in 2019. RN staffing and workload fluctuated widely at the onset of the pandemic. In 2022, new patterns began to emerge, showing a higher RN workload than before the pandemic.

BACKGROUND:Inpatient nurse staffing affects patient outcomes. Less is known about the mechanism of this relationship and how lower overall staffing in a unit affects individual RN activities at the bedside. OBJECTIVES:Estimate the relationship between the number of patients assigned to an RN and time spent on medication administration at the peak-time medication pass (PTM), a common nursing task. RESEARCH DESIGN:Estimate the association using multivariable linear regression to adjust for patient severity and staff and unit fixed effects. SUBJECTS:All 9272 RNs administering medications during the PTM on 243 inpatient units in 113 VHA hospitals in 2019. MEASURES:Number of assigned patients to an RN at PTM; PTM duration. RESULTS:After adjusting for staff and unit fixed effects and average patient severity of illness, the PTM duration for an RN assigned 3 patients is 20.67 (95% CI: 20.31, 21.03) minutes longer than when they are assigned 2 patients. The adjusted difference between 4 and 2 patients is 35.42 (95% CI: 35.01, 35.83). PTM duration per patient declines. Relative to 2 patients, RNs assigned 3 patients spend 0.78 (95% CI: 0.63, 0.93) fewer minutes per patient delivering medications during the PTM (3% reduction), and RNs assigned 4 patients spend 2.52 (95% CI: 2.37, 2.68) fewer minutes (11% reduction). CONCLUSION:Individual nurses spend more time overall delivering medications when assigned more patients. Nurses compensate for the increased patient load by only marginally reducing time spent with each patient, even after controlling for patient severity and other factors.

This Viewpoint discusses the implications that the 2024 presidential election may have on the status of the temporary expansions to the Affordable Care Act’s Advanced Premium Tax Credits.

BACKGROUND:The rising demand for health care delivery and an aging workforce is of particular concern in rural areas, where health care access depends upon an adequate nursing workforce. To address this shortage and optimize care, it is essential to measure when registered nurses (RN) leave inpatient direct care positions (ie, inpatient RN turnover) and identify modifiable factors correlated with RN turnover. OBJECTIVES:Apply a novel method for characterizing inpatient RN turnover to understand factors associated with variation in RNs leaving inpatient positions at rural and urban Veterans Health Administration (VHA) hospitals. PROJECT DESIGN:Retrospective cohort study. SUBJECTS:Direct care RNs working on VHA regular acute care units for at least 15 days across a 60-day period during fiscal year 2022. Measures: outcome: electronic health record (EHR)-derived RN turnover on inpatient medical, surgical, or mixed medical-surgical units; exposure: rurality of hospital location. RESULTS:Among the cohort of 10,415 inpatient RNs in FY22, 3537 RNs left inpatient direct care in FY22 (34.0%). There were 127 inpatient RN turnover events in rural VHA hospitals (42.8% of 297), compared with 3410 in urban (33.7% of 10,118) (P<0.001). However, in the final mixed-effects logistic regression model, individual RN-specific features and care delivery structure, not rurality (P=0.843), were more strongly associated with variation in turnover events. CONCLUSIONS:Inpatient RN turnover was greater in rural versus urban hospitals, but rurality alone was not associated with turnover after multilevel adjustment.

The Veterans Health Administration (VHA), the largest employer of nurses in the United States, has more than 120,000 nursing personnel providing care to over 9 million Veterans across diverse settings. Despite nursing's central role in delivering and sustaining care, research on strengthening the nursing workforce and optimizing nursing practice has remained underdeveloped in VHA. To address this gap, VHA's Office of Research and Development, in partnership with the Office of Nursing Services, convened a State of the Art (SOTA) conference in November 2023 focused on nursing. The Nursing SOTA brought together nurses, researchers, operational leaders, and other stakeholders to review current evidence, identify research gaps, and develop recommendations. Five priority areas were identified: pressure injury prevention and treatment, care coordination models, social drivers of health, nurse staffing and care models, and the nursing work environment. Cross-cutting themes included the need for stronger data infrastructure and expanded support for the VHA nursing science workforce. Conference recommendations were incorporated into VHA's 2024 Health Systems Research Priorities and are expected to inform future research, policy, and practice aimed at advancing nursing science and improving care for Veterans.

RATIONALE: Combined pulmonary fibrosis and emphysema (CPFE) is a distinct clinical entity with different phenotypic characteristics compared to pulmonary fibrosis alone. Veterans are uniquely predisposed to both emphysema and pulmonary fibrosis due to underlying demographic risk factors and exposures. In this study, we examined the epidemiology of CPFE among a national cohort of U.S. Veterans with idiopathic pulmonary fibrosis (IPF). METHODS: We used electronic health record data to identify Veterans with a new diagnosis of IPF between 1/1/2010 and 12/31/2019 using an ICD code-based phenotype and then identified a subgroup of patients with concomitant emphysema using additional ICD codes. We assessed incidence, prevalence, and differences in demographic characteristics, comorbidities, pulmonary function, and antifibrotic utilization using t-test and chi-squared test as appropriate. Survival analysis by IPF versus CPFE phenotype was conducted using univariate and multivariate Cox models adjusted for age, sex, and baseline pulmonary function at diagnosis. RESULTS: We identified 139,116 Veterans with a new diagnosis of pulmonary fibrosis between 2010 – 2019 of which 55,093 (39.6%) had concomitant emphysema. Compared to IPF-only patients, CPFE patients were older (71.9 years vs. 69.9 years, p<0.01), more likely to be White (79.5% vs. 76.5%, p<0.01), and live in rural areas (41.2% vs. 39.1%, p<0.01). CPFE patients were more likely to have a history of tobacco use (91.2% vs. 73.2%, p<0.01), higher prevalences of cardiopulmonary comorbidities including pulmonary hypertension (7.4% vs. 1.5%, p<0.01), lung cancer (8.0% vs. 2.0%, p<0.01), sleep apnea (23.0% vs. 13.0%, p<0.01), heart failure (29.2% vs. 10.3%, p<0.01), pulmonary embolism (3.6% vs. 1.4%, p<0.01), and utilize supplemental oxygen (15.6% vs. 3.7%, p<0.01) at time of index diagnosis. Antifibrotic (nintedanib or pirfenidone) utilization was higher in patients with IPF alone (3.7% vs 1.5%, p<.01). Veterans with CPFE had significantly lower FEV1 % predicted (-15.8%, p<0.01), FEV1/FVC % predicted (-0.09, p<0.01), and DLCO % predicted (-13.8%, p<0.01). CPFE patients had higher mortality rates compared to IPF patients in both unadjusted models (HR 1.74, 95% CI 1.71-1.77) and multivariate models adjusted for age, sex, and baseline FVC (HR 1.33, 95% CI 1.20-1.48). These results persisted in a sensitivity analysis of patients with a narrower case definition of disease using a more restrictive ICD-code based phenotype for IPF. CONCLUSION: CPFE is highly prevalent among Veterans and is associated with greater comorbidity burden, worse pulmonary function, and higher mortality rates. How these patients interface with the healthcare system and the care they receive deserves further investigation.

PURPOSE Depression is associated with poor outcomes in breast cancer survivors (BCSs), with higher prevalence among younger women. The Pathways to Wellness (PTW; ClinicalTrials.gov identifier: NCT03025139 ) randomized controlled trial (RCT) demonstrated beneficial effects of two behavioral interventions (survivorship education [SE] and mindful awareness practices [MAPs]) on depressive symptoms in younger BCS. We conducted an exploratory secondary analysis to identify moderators of intervention effects. METHODS Women diagnosed with stage 0 to III breast cancer at or before age 50 years who completed cancer treatment were randomly assigned to 6 weeks of SE (n = 81), MAPs (n = 85), or waitlist control (WLC; n = 81). Moderators assessed at baseline included psychological distress (depression and anxiety), intervention preference, preparedness for survivorship, and time since initial diagnosis. Linear regression models tested the modifying effects of each variable on postintervention depression in SE versus WLC and MAPs versus WLC. RESULTS Baseline levels of depression (β = –.03, P < .01) and anxiety (β = –.64, P = .02) moderated effects of SE on depressive symptoms, as did preparedness for survivorship (β = 3.17, P = .02). Participants randomly assigned to SE who had the highest levels of depression or anxiety and who felt least prepared for survivorship showed the largest reductions in depressive symptoms from preintervention to postintervention. Similar effects were not observed for MAPs. Intervention preference and time since diagnosis did not moderate intervention effects for either SE or MAPs. CONCLUSION Our 6-week, group-based SE program may be most beneficial for women with higher levels of psychological distress and those who feel least prepared for cancer survivorship. By contrast, a 6-week mindfulness awareness practice intervention appears to benefit younger BCS regardless of pretreatment characteristics.

Importance US surgical quality improvement (QI) programs use data from a systematic sample of surgical cases, rather than universal review of all cases, to assess and compare risk-adjusted hospital postoperative complication rates. Given decreasing postoperative complication rates over time and the types of cases eligible for abstraction, it is unclear whether case sampling is robust for identifying hospitals with higher than expected complications.Objective To compare the assessment of hospital 30-day complication rates derived from sampling strategy used by some US surgical QI programs relative to universal review of all cases.Design, Setting, and Participants This US hospital-level analysis took place from January 1, 2016, through September 30, 2020. Data analysis was performed from July 1, 2022, through December 21, 2022. Quarterly, risk-adjusted, 30-day complication observed to expected (O-E) ratios were calculated for each hospital using the sample (n = 502 730) and universal review (n = 1 725 364). Outlier hospitals (ie, those with higher than expected mortality) were identified using an O-E ratio significantly greater than 1.0. Patients 18 years and older who underwent a noncardiac operation at US Department of Veterans Affairs (VA) hospitals with a record in the VA Surgical Quality Improvement Program (systematic sample) and the VA Corporate Data Warehouse surgical domain (100% of surgical cases) were included.Main Outcome Measure Thirty-day complications.Results Most patients in both the representative sample and the universal sample were men (90.2% vs 91.2%) and White (74.7% vs 74.5%). Overall, 30-day complication rates were 7.6% and 5.3% for the sample and universal review cohorts, respectively (P < .001). Over 2145 hospital quarters of data, hospitals were identified as an outlier in 15.0% of quarters using the sample and 18.2% with universal review. Average hospital quarterly complication rates were 4.7%, 7.2%, and 7.4% for outliers identified using the sample only, universal review only, and concurrent identification in both data sources, respectively. For nonsampled cases, average hospital quarterly complication rates were 7.0% at outliers and 4.4% at nonoutliers. Among outlier hospital quarters in the sample, 54.2% were concurrently identified with universal review. For those identified with universal review, 44.6% were concurrently identified using the sample.Conclusion In this observational study, case sampling identified less than half of hospitals with excess risk-adjusted postoperative complication rates. Future work is needed to ascertain how to best use currently collected data and whether alternative data collection strategies may be needed to better inform local QI efforts.

Background Little is known about the association of discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RA) with outcomes in patients with CKD. Methods We identified adults with CKD stages 3-4 from 2005 to 2022 in the Veterans Affairs health care system. Individuals with an incident prescription for SGLT2 inhibitors or GLP-1 RAs were included, with the first fill date considered the index date. Factors associated with time to first treatment discontinuation, defined as an interruption in SGLT2 inhibitor or GLP-1 RA prescription for >= 90 days, were studied using Cox proportional hazards regression models. Associations of discontinuation 90-179 and >= 180 days with death, myocardial infarction, coronary revascularization, hospitalization for heart failure, and ischemic stroke were assessed using Cox proportional hazards regression. Results Of 96,345 individuals who received an SGLT2 inhibitor and 60,020 who received a GLP-1 RA, at least one discontinuation occurred in 35,953 (37%) of SGLT2 inhibitor users and 28,407 (47%) of GLP-1 RA users. SGLT2 inhibitor users were 24% Black, 71% White, 71% age >= 70, and 84% with CKD stage 3a. GLP-1 RA users were 20% Black, 75% White, 63% age >= 70, and 81% with CKD stage 3a. Black race, Hispanic ethnicity, cerebrovascular disease, peripheral vascular disease, and ischemic heart disease were associated with discontinuation of both drug classes. Female sex and more advanced CKD stage were also associated with SGLT2 inhibitor discontinuation. SGLT2 inhibitor discontinuation >= 180 days was associated with death (adjusted hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.58 to 1.77) and heart failure hospitalization (adjusted HR, 1.26; 95% CI, 1.13 to 1.40). GLP-1 RA discontinuation >= 180 days was associated with death (adjusted HR, 1.97; 95% CI, 1.87 to 2.07), myocardial infarction (adjusted HR, 1.23; 95% CI, 1.11 to 1.36), heart failure hospitalization (adjusted HR, 1.48; 95% CI, 1.33 to 1.64), and ischemic stroke (adjusted HR, 1.24; 95% CI, 1.14 to 1.35). Conclusions SGLT2 inhibitor and GLP-1 RA discontinuation was common and associated with harmful outcomes in adults with CKD.

Abstract Background Team-based primary care (PC) enhances the quality of and access to health care. The Veterans Health Administration (VHA) implements team-based care through Patient Aligned Care Teams (PACTs), consisting of four core members: a primary care provider, registered nurse (RN) care manager, licensed vocational nurse, and scheduling clerk. RNs play a central role: they coordinate patient care, manage operational needs, and serve as a patient point of contact. Currently, it is not known how varying levels of RN staffing on primary care teams impact patient outcomes. Objective This study aims to empirically assess how the stability of RN staffing within team-based primary care affects patient access to care. Methods A retrospective database review using clinical and administrative data from the VHA over 24 months. Participants included 5,897 PC PACTs across 152 VHA healthcare facilities in the United States and its territories. The stability of personnel in the RN role was categorized as: RN continuous churn, RN staffing instability and RN vacancy. All 3 categories were compared to teams with RN stability (i.e., same person in the role for the entire 24-month period). Access measures included: average third-next-available appointment, established patient average wait time in days, urgent care utilization, emergency room utilization, and total inbound-to-outbound PC secure messages ratio. Results RN continuous churn within PACTs had a significant impact on third-next-available appointment (b = 3.70, p < 0.01). However, RN staffing instability and vacancy had no significant relationship with any of the access measures. Several risk adjustment variables, including team full-time equivalency, team stability, relative team size, and average team size, were significantly associated with access to health care. Conclusions Teams are impacted by churn on the team. Adequate staffing and team stability significantly predict patient access primary care services. Healthcare organizations should focus on personnel retention and strategies to mitigate the impact(s) of continuous RN turnover. Future research should examine the relative impact of turnover and stability of other roles (e.g., clerks) and how team members adapt to personnel changes.

OBJECTIVE:Depression is associated with poor outcomes in breast cancer patients, with higher prevalence among younger women. Although mindfulness-based interventions (MBIs) have demonstrated therapeutic effects, the mechanisms of intervention effects are poorly understood. We investigated whether rumination, self-kindness, intrusive thoughts about cancer, cancer-related worry, or a sense of meaning and peace mediated the intervention effects of an MBI, Mindful Awareness Practices (MAPs), on depressive symptoms. Additionally, we explored the same variables as mediators of a psychoeducation program, Survivorship Education (SE). METHODS:Women diagnosed with stage 0-III breast cancer at age <50 years were randomized to 6 weeks of MAPs ( n = 85), SE ( n = 81), or wait-list control (WLC; n = 81). During preintervention, postintervention, and 6-month follow-up (FU), we assessed depressive symptoms, rumination, self-kindness, intrusive thoughts, worry, and meaning and peace. RESULTS:MAPs and SE significantly reduced depressive symptoms at postintervention, and reductions remained through 6-month FU for MAPs. Models revealed that reductions in rumination ( β = -0.68, 95% confidence interval [CI] = -1.64 to -0.07) and intrusive thoughts ( β = 1.17, 95% CI = -2.17 to -0.37) and improvements in self-kindness ( β = -1.09, 95% CI = -2.37 to -0.28) and meaning and peace ( β = -1.09, 95% CI = -3.16 to -0.56) mediated MAPs' effects at all time points. Reductions in worry ( β = -1.34, 95% CI = -2.47 to -0.45]) mediated effects at postintervention only. Worry and intrusive thoughts mediated SE effects at postintervention and 6-month FU, respectively. CONCLUSIONS:Findings identified depression-relevant mediators of MAPs' effects, expanding the understanding of MBI mechanisms. Results highlight pathways that could be leveraged to optimize intervention outcomes. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT03025139 .

Background Breast cancer survivorship guidelines with specific recommendations on managing long-term effects are available, but uptake in clinical practice remains low. Using the lens of the Theoretical Domains Framework, we aimed to understand key factors in guideline-concordant management of long-term effects to inform future implementation efforts in clinical practice contexts.Methods As part of a broader survey of oncologists, a theory-guided questionnaire was developed. Oncologists were asked to report level of agreement with Theoretical Domains Framework-based statements, current usage and perceived value of survivorship resources, and frequency of managing long-term effects in routine care. Data analyses included psychometric assessment of the questionnaire, descriptive summaries of theoretical domains and survivorship resources, and multivariable logistic regression models.Results In total, 217 oncologists completed the Theoretical Domains Framework-based questionnaire; 54% of oncologists reported "always or almost always" evaluating physical effects at routine survivorship appointments, while 34% did so for psychosocial effects. In regression models, Environmental Context and Resources was the only theoretical domain found to be statistically significantly associated with "always or almost always" evaluating both physical (odds ratio = 0.29, 95% confidence interval = 0.09 to 0.80) and psychosocial (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.35) effects.Conclusions Findings support application of the Theoretical Domains Framework in understanding oncologists' behaviors and perceived barriers in managing long-term effects in breast cancer survivors. In future implementation efforts, this theory-informed approach can be used to target relevant domains and strategies focused on embedding guideline recommendations in the clinical context through structured resources and environmental supports.

Objective: To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion. Study Setting: Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year. Study Design: Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year. Data Extraction Methods: We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status. Principal Findings: Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states). Conclusions: Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Background: Fatigue is a common side effect of cancer and its treatment and is thought to be driven in part by activation of the proinflammatory cytokine network. However, the cellular and molecular underpinnings of cancer -related fatigue (CRF) have not been determined, nor have immune pathways beyond inflammation been carefully investigated. The goal of this study was to examine the association between CRF and activation of canonical proinflammatory gene regulation pathways and Type I interferon (IFN) signaling pathways in breast cancer patients during and after treatment. Methods: Women diagnosed with early -stage breast cancer (n = 181) completed assessments before and after treatment with radiation and/or chemotherapy and at 6, 12, and 18 -month post -treatment follow-ups. Assessments included self -reported fatigue (Multidimensional Fatigue Symptom Inventory - Short Form) and expression of pre -specified sets of Type I IFN and pro -inflammatory immune response genes determined from mRNA sequencing of PBMCs. Mixed effect linear models examined changes in fatigue and immune gene expression over time and tested the hypothesis that fatigue would be associated with increased expression of Type I IFN and inflammatory response genes. Results: There were significant changes in fatigue and immune gene expression across the assessment period; all measures increased from pre- to post -treatment but showed diverging patterns over the follow-up, with declines in fatigue and persistent elevations in Type I IFN and proinflammatory gene expression. In mixed effect linear models, expression of Type I IFN response genes was elevated in association with fatigue across the assessment period, from pre-treatment to 18 -month followup. In contrast, pro -inflammatory gene expression was associated with fatigue only at 6, 12, and 18 -month follow-ups. Analyses controlling for changes in leukocyte subsets continued to show a significant association between fatigue and Type I IFN gene expression but reduced the time -dependent association with proinflammatory gene expression to non -significant. Conclusions: Results revealed unexpected complexity in the immune underpinnings of CRF and identify a novel role for IFN signaling as a robust contributor to this symptom before, during, and after treatment. Pro -inflammatory gene expression emerged as a predictor of fatigue later in the cancer trajectory, and that effect was primarily accounted for by a concurrent increase in monocyte prevalence.