BACKGROUND:Pre-Exposure Prophylaxis (PrEP) dramatically reduces the likelihood of acquiring human immunodeficiency virus (HIV), yet it remains under-prescribed, particularly for people in communities with high HIV incidence. While implementation science and health services researchers aim to address disparities in care, few interventions have proven effective in doing so. We aimed to identify implementation strategies associated with higher PrEP prescribing rates and pilot test a tailored intervention as a proof-of-concept in a single Veterans Health Administration (VA) facility. METHODS:VA clinicians were surveyed using an instrument derived from the Evidence-based Recommendations for Implementing Change taxonomy to assess the use of various strategies for PrEP in fiscal years 2019-2021. Correlational analyses identified the strategies associated with the frequency of PrEP prescribing and semi-structured interviews with personnel from 11 VA medical facilities with high PrEP prescribing refined and manualized these strategies into the Getting to Implementation (GTI)-PrEP playbook. The playbook was subsequently pilot tested in a VA facility with high new HIV diagnosis rates and low PrEP prescribing rates. RESULTS:The clinician survey collected 157 responses from 95 unique VA facilities on implementation strategy use. Analysis identified eight strategies significantly associated with PrEP prescribing, including: networking, clinician education, clinical support tools, dashboard utilization, telehealth, pharmacist involvement, direct patient engagement, and enhanced sexual health history taking. In the pilot study, the site completed the GTI-PrEP Playbook with high fidelity and newly implemented seven of the eight strategies, achieving a 363% increase in PrEP prescribing rates among Black Veterans over the one-year period. CONCLUSIONS:This multi-year national evaluation identified a core subset of effective implementation strategies for increasing PrEP prescribing. The process of empirically specifying these strategies and pilot testing them through the GTI-PrEP playbook demonstrates a promising, data-driven approach to improve PrEP prescribing rates and reduce racial disparities in HIV prevention.

BACKGROUND:While guidelines recommend twice-yearly liver cancer (hepatocellular carcinoma, HCC) surveillance for people with cirrhosis, adherence to these guidelines remains variable. We aimed to empirically identify and apply successful implementation strategies through Getting to Implementation (GTI), a manualized facilitation approach. METHODS:A hybrid type III, stepped-wedge, cluster-randomized trial was conducted at 12 underperforming Veterans Health Administration (VA) sites between October 2020 and October 2022. GTI included a stepwise approach to guide sites to detail their current state, set implementation goals, identify implementation barriers, select implementation strategies, make a work plan, conduct an evaluation, and sustain their work. Outcomes were defined using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS:Facilitators supported site teams with an average of 20±6 facilitation hours over a 12-month period. Ten of 12 sites (83%) adopted GTI and applied a median of five strategies (e.g., dashboard use, small tests of change, direct patient outreach). Reach, the primary outcome, increased from mean 29.1% to mean 38.8% at-risk Veterans receiving HCC surveillance from pre- to post-intervention, and further increasing to 41.3% in the sustainment period. In both unadjusted and adjusted models, the odds of HCC surveillance were significantly higher during intervention (adjusted odds ratio, aOR=1.67, 95% CI:1.59, 1.75) and during sustainment (aOR=1.69, 95% CI:1.60, 1.78) compared with baseline, and with difference between active and sustainment periods, indicating sustained improvement after active facilitation ended. CONCLUSIONS:GTI sustainably improved HCC surveillance, suggesting that applying data-driven implementation strategies within a manualized facilitation approach can improve care. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT04178096.

Background The diagnosis-based Human Immunodeficiency Virus (HIV) Care Continuum offers a well-established framework for measuring HIV care quality. It is used by the government agencies, community organizations, and health care institutions to "guide the nation's response to HIV" and assesses HIV care from the time of HIV diagnosis through viral suppression. Our objective is to present the Veteran Health Administration's (VHA) HIV Care Continuum, assess postpandemic versus prepandemic performance, and compare VHA performance to Centers for Disease Control and Prevention-published data. Methods We conducted a nationwide retrospective cohort analysis examining the care continuum for people with HIV (PWH) in VHA care in 2019 versus 2022. Measurements included linkage to care, receipt of care, retention in care, and viral suppression. We used multivariable logistic regression of virological suppression to identify factors associated with viral suppression. Results In VHA in 2019, 83% of individuals newly diagnosed with HIV were linked to care, 84% of PWH received care, 76% were retained in care, and viral suppression was 76% among those with HIV and 93% of those with viral load (VL) results. In 2022, 74% were linked to care, 79% received care, 67% were retained in care, and viral suppression was 70% among those with HIV and 94% of those with a VL result. Conclusions VHA has achieved >90% viral suppression among those with a VL result. Among all PWH, viral suppression decreased an absolute 5.2% between 2019 and 2022. VHA's performance on the HIV Care Continuum exceeds the national HIV Care Continuum reported by the Centers for Disease Control and Prevention.

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BACKGROUND AND AIMS:The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention.APPROACH AND RESULTS:VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews.CONCLUSIONS:In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.

Background Analyses of electronic medical databases often compare clinical practice to guideline recommendations. These analyses have a limited ability to simultaneously evaluate many interconnected medical decisions. We aimed to overcome this limitation with an alternative method and apply it to the diagnostic workup of HIV, where misuse can contribute to HIV transmission, delay care, and incur unnecessary costs. Methods We used graph theory to assess patterns of HIV diagnostic testing in a national healthcare system. We modeled the HIV diagnostic testing guidelines as a directed graph. Each node in the graph represented a test, and the edges pointed from one test to the next in chronological order. We then graphed each patient’s HIV testing. This set of patient-level graphs was aggregated into a single graph. Finally, we compared the two graphs, the first representing the recommended approach to HIV diagnostic testing and the second representing the observed patterns of HIV testing, to assess for clinical practice deviations. Results The HIV diagnostic testing of 1.643 million patients provided 8.790 million HIV diagnostic test results for analysis. Significant deviations from recommended practice were found including the use of HIV resistance tests (n = 3,007) and HIV nucleic acid tests (n = 16,567) instead of the recommended HIV screen. Conclusions We developed a method that modeled a complex medical scenario as a directed graph. When applied to HIV diagnostic testing, we identified deviations in clinical practice from guideline recommendations. The model enabled the identification of intervention targets and prompted systemwide policy changes to enhance HIV detection.

After implementing a successful hepatitis C elimination program, the Veterans Health Administration’s (VHA) Hepatic Innovation Team (HIT) Collaborative pivoted to focus on improving cirrhosis care. This national program developed teams of providers across the country and engaged them in using systems redesign methods and population health approaches to improve care. The HIT Collaborative developed an Advanced Liver Disease (ALD) Dashboard to identify Veterans with cirrhosis who were due for surveillance for hepatocellular carcinoma (HCC) and other liver care, promoted the use of an HCC Clinical Reminder in the electronic health record, and provided training and networking opportunities. This evaluation aimed to describe the VHA’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates, using a quasi-experimental design. Across all VHA facilities, as the HIT focused on cirrhosis between 2018–2019, HCC surveillance rates increased from 46% (IQR 37–53%) to 51% (IQR 42–60%, p < 0.001). The median HCC surveillance rate was 57% in facilities with high ALD Dashboard utilization compared with 45% in facilities with lower utilization (p < 0.001) and 58% in facilities using the HCC Clinical Reminder compared with 47% in facilities not using this tool (p < 0.001) in FY19. Increased use of the ALD Dashboard and adoption of the HCC Clinical Reminder were independently, significantly associated with HCC surveillance rates in multivariate models, controlling for other facility characteristics. In conclusion, the VHA’s HIT Collaborative is a national healthcare initiative associated with significant improvement in HCC surveillance rates.

Background To measure the incidence of syphilis diagnoses among people with HIV vs those without HIV in a national multiyear retrospective cohort. Methods Treponemal and nontreponemal tests, HIV status, and demographic data were identified among all individuals receiving Veterans Health Administration (VHA) care between January 1, 2009, and December 31, 2019. Syphilis testing rates and incident syphilis diagnoses as defined by a laboratory algorithm were stratified by HIV status. Results Syphilis was diagnosed in 1.2% (n = 2283) of 194 322 tested individuals in VHA care in 2019. Among individuals with HIV tested for syphilis, 6.1% met criteria for syphilis compared with 0.7% without HIV. Syphilis incidence in 2019 was 35/100 000, a 17% increase from 2009 (30/100 000). In 2019, syphilis incidence was 3381 per 100 000 persons among individuals with HIV and 19 per 100 000 in those without HIV. Conclusions Using a laboratory-based diagnostic algorithm, a 178-fold difference in syphilis incidence was observed between individuals with and without HIV in 2019. US syphilis incidence data that incorporate HIV status are needed. Interventions to monitor and prevent sexually transmitted infections should address the role of HIV status.

Content available: Audio Recording Since 2014, the US Department of Veterans Affairs (VA), the largest single provider of care for chronic hepatitis C virus infection (HCV) in the United States, has virtually eliminated HCV among Veterans in VA care (Fig. 1). The VA's experience provides lessons learned to other healthcare organizations (HCOs) pursuing HCV elimination. The discovery two decades ago that HCV is three times more prevalent among Veterans in VA care than in the general US population1, 2 prompted the VA to launch a comprehensive national HCV program focused on provider and patient education, quality improvement, data dissemination, and clinical tool deployment (Table 1). The VA's national HCV treatment efforts were limited by the low efficacy and high toxicity of interferon-based HCV treatments, along with the high prevalence among Veterans in VA care with HCV.7 Consequently, by 2014, fewer than 25% of approximately 170,000 Veterans with HCV in VA care had received treatment, with only 10% achieving a sustained viral response (SVR). The VA's robust organizational HCV infrastructure – particularly the creation of a national HCV clinical case registry by the VA's Population Health office – prepared the VA to respond quickly when all-oral DAAs became available in 2014. Using this pre-existing foundation, the VA activated a unique network of VA Hepatitis C Innovation Teams (HITs) – small, agile, field-based units focused on rapid clinical system redesign and innovation to improve HCV care. The HIT concept followed Berwick's framework for innovation dissemination in healthcare, which posits the importance of first identifying strong evidence-based practices and innovators, investing in and learning from early adopters, supporting change, and leading by example (Table 2).8 HITs were established within each Veterans Integrated Service Network (VISN; a geographic region containing multiple VAMCs). Each HIT was composed of subject matter experts (SMEs) in HCV, clinical pharmacy, system redesign, and informatics. Each VISN HIT was funded by the national HCV program but focused on issues specific to that VISN. As described below, the HITs had the same quantitative access and quality goals but were autonomous in choosing the route and projects for achieving these targets. We surveyed VA HCV clinicians and HIT participants about 73 implementation strategies or activities used at their facility. Implementation strategy definitions followed the Expert Recommendations to Implement Change (ERIC).9 Each strategy was evaluated for the strength of its association with the number of DAA treatment starts at each facility from 2015 to 2019.10-12 Eight implementation strategies, clustered thematically into three groups, were consistently associated with higher annual DAA treatment starts. These strategies, described below, provide an HCV-elimination roadmap for public health agencies and other HCOs (Table 2). A national leadership team (LT) that included VA leadership, a hepatologist, and personnel trained in public health, informatics, and systems redesign oversaw the VISN HITs (Fig. 2). The LT supported HITs to identify barriers to HCV testing and treatment and to set ambitious annual goals for testing and treatment. The LT provided training and coaching to HITs on Lean process improvement, data management, and HCV clinical care/DAA use. The LT also sponsored work groups and established online and in-person opportunities for peer-to-peer networking and sharing ideas as well as facilitating communication with higher level policy makers. The LT prioritized a culture of safety and innovation, embracing failure as a precursor to change. The LT facilitated the development of 20 VISN HITs, each with a designated leader and a multidisciplinary membership from the facility-based teams within the VISN. The HITs used Lean principles, derived from industrial engineering, to improve healthcare efficiency while maintaining the central importance of the patient.13, 14 VISN HITs retained autonomy to establish regional goals and prioritize innovations that met regional needs. HITs used A3 problem solving, tracked their progress, and shared their successes and challenges (Fig. 3). VISN teams worked closely with local facility and clinic leaders, facilitating consistent communication in a rapidly changing policy landscape. The LT identified 'early adopters,' who successfully applied Lean to achieve innovations in HCV care and DAA treatment.15 Early adopters presented to their peers during national and regional team calls. A virtual platform allowed teams to share their experiences with members who could not attend structured meetings. The VA's preexisting clinical case registry (CCR) had data on all Veterans in VA care known to have HCV, with individual facilities having local CCRs.3 However, DAA availability created a pressing need for user-friendly and locally available methods to identify and link Veterans with HCV to care. To improve access to this information, several VISN HITs independently developed user-friendly HCV Dashboards, which were coalesced to create a national Dashboard. These data were then used by providers at each facility to identify untreated patients and by the LT to monitor progress across the VA, creating positive competition for quality improvement. A suite of tools was created to document HCV screening, evaluation, and treatment decisions. Tools also included triggers within the electronic medical record to prompt re-evaluation of Veterans who had previously deferred HCV treatment. This platform allowed the LT to collect data from users that could inform policy. Because the HCV Dashboard was built to meet the needs of stakeholders, it was widely accepted by the HITs and was critical in the paradigm shift from referral-based HCV treatment to non-specialist care by primary care physicians and clinical pharmacists. The most successful HITs changed the way HCV care was delivered by engaging non-traditional providers in treating HCV. Pharmacist-led clinics, group visits, and primary care treatment were all used to expand capacity and treat outside of the traditional hepatology and infectious diseases settings. Approximately 30% of DAA treatment was managed by clinical pharmacists, with SVR rates similar to Veterans receiving treatment by specialists. VA recognized the need to assess patients for cirrhosis and to evaluate patients with cirrhosis for liver cancer prior to initiating HCV treatment. As such, improving access to ultrasound examination and vibration-controlled transient elastography to assess liver fibrosis was critical to screen and risk-stratify patients prior to treatment initiation. Therefore, funds were provided to purchase elastography and other equipment. The HIT infrastructure also supported a working group of providers to develop and disseminate tools and training about transient elastography methods and equipment. Two decades of leadership by dedicated VA clinicians supported by the VA National HCV Program Office provided the infrastructure for rapid expansion of HCV care following the availability of DAAs in 2014. These efforts included testing Veterans in VA care for HCV, identifying HCV lead clinicians, and using a population health management tool. The HITs used Lean approaches to identify and overcome local barriers to care. The implementation strategies empirically associated with higher treatment were also those that aligned with the Theory of Dissemination of healthcare innovations.8 As a learning healthcare system, the VA is now applying these lessons and approaches to improve care in the areas of HIV prevention and care and cirrhosis care. This work can serve as an example for other healthcare organizations aiming to eliminate HCV.

Background. Chlamydia trachomatis and Neisseria gonorrhoeae cases reached a record high in the United States in 2018. Although active-duty military service members have high rates of chlamydia and gonorrhea infection, trends in chlamydia and gonorrhea in the Veterans Health Administration (VHA) system have not been previously described, including among patients living with human immunodeficiency virus (HIV) and young women. Methods. We identified all veterans in VHA care from 2009 through 2019. Tests and cases of chlamydia and gonorrhea were defined based on laboratory results in the electronic health record. Chlamydia and gonorrhea incidence rates were calculated each year by demographic group and HIV status. Results. In 2019, testing for chlamydia and gonorrhea occurred in 2.3% of patients, 22.6% of women aged 18-24 years, and 34.1% of persons living with HIV. The 2019 incidence of chlamydia and gonorrhea was 100.8 and 56.3 cases per 100 000 VHA users, an increase of 267% and 294%, respectively, since 2009. Veterans aged <= 34 years accounted for 9.5% of the VHA population but 66.9% of chlamydia and 42.9% of gonorrhea cases. Chlamydia and gonorrhea incidence rates in persons living with HIV were 1432 and 1687 per 100 000, respectively. Conclusions. The incidence of chlamydia and gonorrhea rose dramatically from 2009 to 2019. Among tested persons, those living with HIV had a 15.2-fold higher unadjusted incidence of chlamydia and 34.9-fold higher unadjusted incidence of gonorrhea compared with those not living with HIV. VHA-wide adherence to chlamydia and gonorrhea testing in high-risk groups merits improvement.

Background United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans may be at increased risk for STIs due to high rates of sexual trauma. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans. Objective To examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the Veterans Health Administration (VHA) in 2019. Design We performed a retrospective cohort study of all women Veterans in VHA care between January 1, 2018, and December 31, 2019. Participants Women Veteran patients were identified as receiving VHA care if they had at least one inpatient admission or outpatient visit in 2019 or the preceding calendar year. Key Results Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, correlates of testing in women under age 25 included Black race (aOR: 2.11, CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05, CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (chlamydia case rate: 265, gonorrhea case rate: 97/100,000) and those with mental health diagnoses (chlamydia case rate: 263, gonorrhea case rate: 72/100,000.) Conclusions Gonorrhea and chlamydia testing remains underutilized among women in VHA care, and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates.

BACKGROUND AND AIMS:Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis.APPROACH AND RESULTS:This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96).CONCLUSIONS:Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

Background: The Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus (HCV) than any other US health care system. We tracked the implementation strategies that VA sites used to implement highly effective new treatments for HCV with the aim of uncovering how combinations of implementation strategies influenced the uptake of the HCV treatment innovation. We applied Configurational Comparative Methods (CCMs) to uncover causal dependencies and identify difference-making strategy configurations, and to distinguish higher from lower HCV treating sites. Methods: We surveyed providers to assess VA sites' use of 73 implementation strategies to promote HCV treatment in the fiscal year 2015. CCMs were used to identify strategy configurations that uniquely distinguished higher HCV from lower HCV treating sites. Results: From the 73 possible implementation strategies, CCMs identified 5 distinct strategy configurations, or "solution paths." These were comprised of 10 individual strategies that collectively explained 80% of the sites with higher HCV treatment starts with 100% consistency. Using any one of the following 5 solution paths was sufficient to produce higher treatment starts: (1) technical assistance; (2) engaging in a learning collaborative AND designating leaders; (3) site visits AND outreach to patients to promote uptake and adherence; (4) developing resource sharing agreements AND an implementation blueprint; OR (5) creating new clinical teams AND sharing quality improvement knowledge with other sites AND engaging patients. There was equifinality in that the presence of any one of the 5 solution paths was sufficient for higher treatment starts. Conclusions: Five strategy configurations distinguished higher HCV from lower HCV treating sites with 100% consistency. CCMs represent a methodological advancement that can help inform high-yield implementation strategy selection and increase the efficiency and effectiveness of future implementation efforts.

We assessed hepatitis A (HepA) vaccine receipt among susceptible individuals in outbreak and matched nonoutbreak states. Difference-in-differences models and multivariable logistic regression were used to compare HepA vaccination rates in these states. In the postoutbreak year, there was a 112% increase in HepA vaccinations in outbreak states versus a 6% decrease in nonoutbreak states. Differences persisted in our multivariable model (adjusted odds ratio = 2.53; 95% confidence interval = 2.45, 2.61). HepA vaccination rates increased dramatically in outbreak states, but many individuals susceptible to hepatitis A virus remain unvaccinated. (Am J Public Health. 2022;112(7):990–994. https://doi.org/10.2105/AJPH.2022.306845 )

BACKGROUND & AIMS: Military veterans have been reported to have higher odds of hepatitis B virus (HBV) exposure after adjustment for demographic factors, family income, and birthplace. It is not clear whether military-related exposures are associated with risk of HBV exposure in veterans. METHODS: A random sample of veterans receiving care from 1998 through 2000 in the national Veterans' Health Administration system completed a risk factor survey and underwent phlebotomy analysis (N = 1146). Stored serum samples were reanalyzed to determine prevalence of HBV exposure (core antibody positive), infection (surface antigen or DNA positive), and immunity (surface antibody positive, surface antigen negative, and core antibody negative). Associations between military-related risk factors and HBV exposure were assessed using logistic regression. RESULTS: The prevalence values for infection, exposure, and immunity were 0.7% (95% CI, 0.3-1.5), 13.6% (95% CI, 11.5-16.1), and 6.2% (95% CI, 4.7-8.2), respectively. Evidence of HBV exposure was highest among respondents with traditional risk factors (such as drug use or high-risk sexual practices). More than half the individuals with HBV exposure (53%) reported no history of traditional risk factors; of these, 59.5% reported a history of combat exposure. After adjustment for demographic and traditional risk factors, service in a combat zone (adjusted odds ratio, 1.56; 95% CI, 1.01-2.41) and being wounded in combat (adjusted odds ratio, 1.79; 95% CI, 1.04-3.08) were associated independently with exposure to HBV. CONCLUSIONS: In an analysis of US military veterans, we found the prevalence of exposure to HBV to be highest among veterans with traditional risk factors but also independently related to military combat or being wounded in combat. Studies are needed to determine whether veterans with combat exposure before the era of universal vaccination should be screened for HBV exposure.

BACKGROUND AND AIMS:The Veterans Health Administration (VA) cares for over 80,000 Veterans with cirrhosis annually. Given the importance of understanding patient reported outcomes in this complex population, we aimed to assess the associations between attitudes towards care, disease knowledge, and health related quality of life (HRQoL) in a national sample.METHODS:In this cross-sectional study, we mailed paper surveys to a random sample of Veterans with cirrhosis, oversampling those with decompensated disease. Surveys included the Veterans RAND 12-Item Health Survey (measuring HRQoL) and questions about demographics, characteristics of care, satisfaction with care ("attitudes towards care"), and symptoms of cirrhosis. Those who reported being "unsure" about whether they had decompensation events were defined as "unsure about cirrhosis symptoms" ("disease knowledge"). We used multivariable regression models to assess the factors associated with HRQoL.RESULTS:Of 1374 surveys, 551 (40%) completed surveys were included for analysis. Most Veterans (63%) were "satisfied" or "very satisfied" with VA liver care. Patients often self-reported being unsure about whether they had experienced hepatic decompensation events (34%). Overall average physical (PCS) and mental (MCS) component scores of HRQoL were 30±11 and 41±12. In multivariable regression models, hepatic decompensation (PCS:β = -3.8, MCS:β = -2.2), medical comorbidities (β = --2.0, β = -1.7), and being unsure about cirrhosis symptoms (β = -1.9, β = -3.3) were associated with worse HRQoL, while age (β = 0.1, β = 0.2) and satisfaction with care (β = 0.6; β = 1.6) were associated with significantly better HRQoL.CONCLUSIONS:Hepatic decompensation, lower satisfaction with care, and being unsure about cirrhosis symptoms were associated with reduced QOL scores in this national cohort.