OBJECTIVE:Initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery for head and neck squamous cell carcinoma (HNSCC) is a National Comprehensive Cancer Network (NCCN) guideline and quality metric. However, guideline concordance in the Veteran population remains unknown. This study evaluates the effect of time to PORT on overall survival (OS) and factors associated with PORT delay among Veterans with HNSCC. STUDY DESIGN:This is a retrospective cohort study of Veterans with HNSCC. SETTING:Patients with HNSCC from 2012 to 2022, identified from the National Veteran's Affairs Database, were included. METHODS:Data were extracted for clinical/demographics, tobacco/alcohol use, area deprivation index, Elixhauser score, body mass index, rurality, travel distance, and location of radiation. Analyses conducted were bivariate comparisons via chi-square and Wilcoxon rank-sum test, as well as adjusted survival analyses and adjusted multivariable logistic regression modeling. RESULTS:Among 2719 HNSCC Veterans who received surgery and adjuvant radiation nationwide, 1638 (60.2%) received PORT within 6 weeks of surgery. On multivariable analysis, factors associated with PORT delay greater than 6 weeks included being unmarried (P = .0275), having an oral cavity primary subsite (P < .0001), and undergoing surgery at the VA and radiation in the community (P < .0001). Three-year OS was higher among those who received PORT within 6 weeks (70.2%) compared to those who received PORT greater than 6 weeks postoperatively (62.1%, P < .001). CONCLUSION:Veterans with HNSCC receive guideline-concordant PORT at a rate of 60.2%. Being unmarried, having oral cavity cancer, and community radiation were associated with PORT delay.

This paper describes the rationale and radiology considerations in the implementation of the Preventing Liver Cancer Mortality through Imaging with Ultrasound versus MRI (PREMIUM) study. PREMIUM is a multicenter, randomized controlled trial sponsored by the Department of Veterans Affairs comparing dynamic contrast-enhanced (DCE) abbreviated MRI (aMRI) plus serum AFP versus ultrasound (US) plus serum AFP for hepatocellular carcinoma (HCC) screening in patients with cirrhosis. PREMIUM aims to randomize 4,700 participants across over 47 Veterans Affairs Medical Centers to semiannual surveillance for up to eight years, with HCC-related mortality as the primary endpoint. To date, 35 sites have been activated with 1,085 patients randomized. To ensure uniform implementation and reporting of per-protocol screening, the PREMIUM Radiology Workgroup developed standardized imaging protocols, structured LI-RADS–based reporting templates, and a centralized training program for radiologists and technologists. They also perform ongoing quality control on both scans and reports. The aMRI protocols utilize multiphasic post-contrast imaging to allow LI-RADS scoring. A non-contrast-enhanced aMRI protocol is available for participants who develop renal impairment or contrast allergy during the study. US protocols conform to US LI-RADS standards. Structured reporting promotes consistency in documentation of findings, visualization scores, and follow-up recommendations. A centralized Image Repository was established, incorporating advanced de-identification methods to remove metadata and pixel-embedded protected health information from imaging files. More than 20,000 curated liver MRI and US exams are anticipated, supporting both trial outcomes and future radiomics and artificial intelligence research. PREMIUM aims to determine whether screening for HCC with a DCE aMRI protocol reduces HCC-related mortality and also facilitates ancillary studies utilizing the Image Repository.

Medication adherence is critical to long-term graft and patient survival after liver transplantation (LT), yet the effectiveness of adherence-promoting interventions across the post-transplant survivorship continuum remains uncertain. We systematically reviewed interventions to improve medication adherence, including immunosuppressive regimen simplification, pharmacist-led or counseling strategies, behavioral and multicomponent programs, and technology-based interventions. We identified 33 studies: immunosuppressive regimen simplification (n=8), pharmacist-led or counseling strategies (n=6), behavioral or multicomponent programs (n=3), virtual visits/remote monitoring (n=9), and mobile or text-based tools (n=7). In pooled analyses of randomized trials, active interventions improved adherence versus usual care (OR 4.04, 95% CI 1.94-8.41), although heterogeneity was substantial. A higher prevalence of alcohol-associated liver disease was associated with weaker intervention effects. Regimen simplification, especially conversion from twice-daily to once-daily tacrolimus, showed consistent improvement in adherence while maintaining acceptable graft outcomes. Pharmacist-led interventions improved medication knowledge, dosing compliance, and drug monitoring. Telehealth interventions reduced travel burden and, in some studies, early readmissions and hospital stays. Overall, regimen simplification and structured multidisciplinary support appear most effective, but larger longitudinal trials with standardized adherence measures are needed.

BACKGROUND:Chronic pain is common and uniquely challenging to manage in people with cirrhosis. The purpose of this pilot study was to evaluate the feasibility and acceptability of a tailored pain self-management (PSM) intervention for people with cirrhosis and chronic pain. METHODS:This single-arm, single-site pilot study recruited patients with a diagnosis of cirrhosis and chronic pain to a virtual, health coach-led, modular PSM intervention. After 6 weekly one-on-one sessions, patients were invited to attend 6 weekly group sessions. Outcomes were measured at baseline, 6 weeks, 12 weeks (end of intervention), and 24 weeks (maintenance). The primary outcomes were acceptability, defined by a 4/5 rating on the Treatment Acceptability Questionnaire, and feasibility, defined as the ability to retain patients in 80% of the intervention sessions. Secondary outcomes of pain and function were measured using the Pain intensity, Enjoyment of life, and General activity (PEG) scales, and a rating of percent improvement with the intervention. RESULTS:Among 21 participants who started the intervention, 16 (76%) attended ≥80% of sessions. Acceptability thresholds were met at all time points. On a scale of 0-100, where 30 is considered to be a meaningful change, participants rated their improvement in pain symptoms an average of 50 ± 25. The average PEG score decreased from 6.1 at baseline to 5.3 at 24 weeks. Participants reported increases in PSM behaviors, including cognitive and stress-reduction methods, physical activity, healthy sleep behaviors, and changes in diet. CONCLUSIONS:This pilot identified a reduction in pain and an increase in PSM activities and demonstrated the acceptability of a health coach-led PSM intervention for adults with chronic pain and cirrhosis.

INTRODUCTION:Office-based opioid treatment with buprenorphine for opioid use disorder (OBOT-BUP) is most effective when patients are retained in treatment long-term, but average treatment duration is less than 6 months. Up to two thirds of individuals with opioid use disorder (OUD) have chronic pain. Treatment of chronic pain in OBOT-BUP settings could improve retention in OBOT-BUP programs. Therefore, this study qualitatively assessed how to tailor pain self-management (PSM) to people with co-occurring chronic pain and OUD in OBOT-BUP settings. METHODS:This study takes a Qualitative Description approach to data collection and interpretation. We conducted semi-structured qualitative interviews with 61 participants (23 clinicians/clinic staff and 38 patients) at OBOT-BUP clinics regarding experiences with chronic pain and its treatment, experiences with opioid use disorder and its treatment, and their thoughts the desirability, feasibility, and modification of a previously developed PSM program for patients with comorbid chronic pain and opioid use disorder. Interviews were coded using a primarily inductively developed codebook, and coding was used to conduct a thematic analysis of interview transcripts. RESULTS:Participants generally reacted positively to the PSM program as presented. We identified 4 themes in the data that could affect implementation of PSM, and/or that suggested modifications that should be made to the program. (1) Patients reported relying on a wide array of treatment modalities, bolstering the case for use of PSM, but also sometimes expressing resistance to the idea if past attempts at PSM components had been unsuccessful. (2) Patients' prior experiences of stigma related to OUD negatively impacted willingness to participate in a PSM intervention. (3) Effective pain management using buprenorphine was regarded as a vital companion to PSM in patients with chronic pain and OUD. (4) Participants identified several aspects of PSM implementation that would be important, including individual sessions, peer-led group sessions, and remote visits. CONCLUSIONS:Participants reported interest in PSM, but also reluctance based in concerns about efficacy and/or fear of stigma. We identified several strategies to respond to these concerns, including positioning PSM as an evidence-based strategy that works adjunctive to buprenorphine, and directly addressing pain/OUD stigma.

Abstract Background While facilitation is a widely used implementation strategy with proven effectiveness, the development of the facilitator-recipient relationship, i.e., working alliance, has received limited attention. However, we hypothesize that working alliance may be part of the mechanism by which facilitation activates change. This study aimed to examine the associations between working alliance, facilitation, and change in clinical care in a hybrid type 3 trial of a manualized intervention, Getting to Implementation (GTI). Methods This concurrent triangulation mixed-methods study was conducted at 12 sites in a stepped-wedge trial. We collected surveys using the Working Alliance Inventory–Short instrument (WAI), which includes three subscales of goal alignment, task alignment, and affective bond, from three respondent types (clinical facilitator, evaluation facilitator, and site team members) after a year of intervention. Facilitation activity type and dose were tracked. Summative qualitative interviews with site champions and facilitators) elicited perceptions on working alliance, facilitation, and experiences with the intervention, and results were triangulated with statistical bivariate analyses. The associations between WAI and facilitation time, fidelity, and change in liver cancer screening rate (the primary trial outcome) were assessed. Results Across 12 sites, facilitators and site team members completed 21 interviews and 40 WAI surveys, with site aggregate average working alliance scores of 5.9 ± 0.4 on a seven-point scale. Bond scores were highest (6.1 ± 0.5), followed by Goal (6.0 ± 0.4) and Task (5.8 ± 0.5) scores. Overall and subscale scores differed by respondent type, with site respondents consistently rating items higher than facilitators, particularly in Task items. Fidelity to the GTI process (e.g., timely completion of steps and tools) was significantly positively associated with WAI scores overall (r = 0.41, p = 0.007) and subscale scores, including Goal (r = 0.39, p = 0.011), Task (r = 0.42, p = 0.006), and Bond (r = 0.33, p = 0.039). WAI scores were not correlated with facilitation time (dose). WAI scores overall and the Bond and Goal scores were significantly positively associated with sustained improvement in cancer screening rates (r = 0.57, p = 0.015). Conclusions In this implementation trial, working alliance between site teams and facilitators was positively associated with both fidelity and cancer screening outcomes and was notably independent of time spent providing facilitation. Findings highlight the importance of working alliance in implementation studies. Trial registration This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

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 and Aims: Up-to-date information is needed on hepatocellular carcinoma (HCC) diagnosis, stage, treatment, and survival. Methods: Of > 2000 patients with a new diagnosis of HCC in 2023 in the US Veterans Health Administration, a random subsample of 194 confirmed HCC cases were selected for a structured medical record review by expert hepatologists. Results: Among 194 confirmed HCC cases in 2023, mean age was 73 years, and only 56.7% had cirrhosis diagnosed before HCC, while 12.9% had cirrhosis diagnosed after HCC and 22.2% did not have cirrhosis. Stage at diagnosis was T1 in 17.5%, T2 in 42.3%, and beyond T2 in 40.2%. Early-stage diagnosis (T1 or T2) was more common in the following groups: cirrhosis diagnosed before HCC (70.9%), HCC diagnosed by screening (86.3%), high performance status (73.0%), receipt of Veterans Affairs (VA) primary care (63.3%), or VA liver care (72.6%). Among 147 of 194 patients (75.8%) who received HCC-directed treatments, the most common, first-line treatment was Y-90 radioembolization (28.6%), followed by ablation (21.1%), transarterial chemoembolization (20.4%), systemic therapy (17.0%), surgical resection (7.5%), and external beam radiation (5.4%). Mortality (29.9% at 1 year, 44.8% at 2 years) was lower in those with early-stage diagnosis, diagnosis via screening, Child-Turcotte-Pugh class A, Model for End-Stage Liver Disease ≤ 10, absence of cirrhosis, cured hepatitis C virus, receipt of curative treatments, VA primary or liver care, and good performance status. Conclusion: These results highlight the importance of HCC screening and engagement in liver care for early HCC diagnosis, curative treatment, and improved survival while demonstrating the feasibility of a national quality improvement program for addressing persistent gaps in the HCC screening, diagnosis, and treatment.

Despite improved survival, liver transplantation (LT) recipients need interventions that promote survivorship including better quality of life. This systematic review describes the goals and quality of existing post-LT interventions to identify gaps in post-LT care. Published manuscripts and registered clinical trials were identified using MEDLINE, PsycINFO, Cochrane, and Scopus from inception to January 1, 2024. Articles and trials were included if they described patient-facing interventions targeting health behaviors, patient-centered outcomes, or preventative health. Data extraction and intervention quality were assessed using applicable trial standards. A total of 61 published manuscripts and 18 registered trials were identified in: (1) alcohol (n=14); (2) diet/nutrition (n=7), education (n=5), symptom management (n=11), preventative health (n=8), physical activity (n=19), and psychosocial issues (n=15). Most interventions were in the early phases of development or pilot testing and targeted the perioperative period up to 1-year post-LT, with fewer interventions targeting >1-year post-LT. There is good evidence to suggest that multidisciplinary programs with integrated psychiatric resources can reduce alcohol relapse post-LT; in-person multimodal interventions including individualized counseling, exercise prescriptions, and educational materials, improved strength, body composition, and quality of life. Multidisciplinary clinics integrating education, free resources, and clinical exams are beneficial in skin cancer prevention and cardiovascular risk modification. The best supported psychosocial interventions include support groups and in-person individualized counseling. Limited high-quality studies exist in diet/nutrition and education. For post-LT survivorship interventions, there is wide variation in intervention quality and limited investigation beyond 1 year post-LT. There is good evidence supporting multidisciplinary clinics/programs to prevent alcohol relapse, enhance physical activity, and facilitate cancer screening. There is limited data on promoting post-LT education, as well as social work and caregiver interventions. Future research should consider these areas for study; high-quality interventions need to incorporate stakeholder input, target later LT survivorship stages, and apply consistent definitions of patient-centered outcomes using validated measures.

Abdominal ultrasound every 6 months with or without serum alpha-fetoprotein (AFP) is recommended for hepatocellular carcinoma (HCC) screening in patients with cirrhosis. However, high-quality evidence demonstrating that this screening strategy reduces HCC-related mortality in cirrhosis is lacking. Dynamic contrast-enhanced abbreviated MRI (DCE aMRI) protocols for HCC screening have nearly identical performance to full multiphasic MRI (the gold standard for HCC diagnosis) and can be completed in under 15 min. PREMIUM is a multicentre randomised controlled trial comparing HCC screening by ultrasound+AFP every 6 months vs. DCE aMRI+AFP every 6 months for up to 8 years among patients with cirrhosis. Sponsored by and executed within the Department of Veterans Affairs (VA), participant recruitment began in November 2023. Eligible participants are Veterans aged 18-75 years with cirrhosis, high HCC risk, Child-Turcotte-Pugh (CTP) score ≤9, model for end-stage liver disease (MELD) score ≤20, and no MRI contraindications or life-threatening comorbidities. The DCE aMRI protocol consists of T1-weighted axial pre-contrast and DCE sequences (arterial, portal, and 5-minute delayed) following administration of extracellular gadolinium-based contrast agent, plus a T2-weighted sequence between portal and delayed phases. PREMIUM aims to randomise 4,700 participants (2,350 in each arm), who will undergo per-protocol imaging and follow-up for up to 8 years. The primary outcome is HCC-related mortality. Secondary outcomes include HCC stage at diagnosis, receipt of potentially curative HCC treatment, and all-cause mortality. The study is powered to detect at least a 35% relative reduction in HCC-related mortality in the aMRI+AFP arm vs. the ultrasound+AFP arm. If PREMIUM demonstrates reduced HCC-related mortality in the aMRI+AFP arm, it could provide the necessary evidence to recommend aMRI+AFP for HCC screening in patients with cirrhosis (ClinicalTrials.gov identifier: NCT05486572). The PREMIUM Study is a registered clinical trial: NCT05486572.

Background: Despite caring for patients with serious illnesses, gastroenterology (GI) fellows rarely receive training in serious illness conversations (SIC). Objectives: To describe the development, implementation, and assessment of GITalk, a novel SIC training for GI fellows. Design: GITalk was based on the REMAP framework and involved two simulated encounters. One case involved a patient with decompensated cirrhosis, and the other case was about feeding tube placement in someone with moderate to severe dementia. Setting and Subjects: GI fellows in an academic medical center in the USA. Measurements: Demographics of the participants, evaluation of the course content, and self-assessed preparedness for SIC. Results: A total of 23 GI fellows participated over 4 consecutive years. Participants had significantly higher mean post-training self-assessed preparedness scores compared to pre-training across all 9 survey questions. 91% of participants strongly agreed with the statement: "I would recommend this training to other fellows." Conclusions: Participants in GITalk reported substantial improvement in self-assessed preparedness for navigating SIC.

BACKGROUND:Screening for gastrointestinal (GI) cancers, specifically colorectal cancer (CRC) and hepatocellular carcinoma (HCC), is often inadequately and inequitably implemented, leading to preventable morbidity and mortality. This protocol paper describes a study designed to compare the effectiveness of external facilitation with patient navigation across hospitals in the Veterans Health Administration (VA). METHODS:Two hybrid type 3, cluster-randomized trials will compare the effectiveness of patient navigation versus external facilitation for supporting HCC and CRC screening completion. Twenty-four sites will be included in the HCC trial and 32 in the CRC trial, cluster-randomizing Veterans by their site of primary care. The primary outcome of reach of cancer screening completion will be measured after intervention and during sustainment. Multi-level implementation determinants (i.e., barriers and facilitators), preconditions, and moderators will be evaluated pre- and post-intervention, using Consolidated Framework for Implementation Research (CFIR)-mapped surveys and interviews of Veteran participants and provider participants. DISCUSSION:Comparing findings in the two trials will allow researchers to understand how implementation barriers and strategies operate differently for a one-time screening in a relatively healthy population (CRC) vs. repeated screening in a more medically complex population (HCC). TRIAL REGISTRATION:This project was registered at ClinicalTrials.Gov (NCT06458998) on 6/13/24.

Abstract Background Because cirrhosis is often unrecognized, we aimed to develop a stepwise screening algorithm for cirrhosis in the Veterans Health Administration (VHA) and assess this approach’s feasibility and acceptability. Methods VHA hepatology clinicians (“champions”) were invited to participate in a pilot program from June 2020 to October 2022. The VHA Corporate Data Warehouse was queried to identify Veterans with possible undiagnosed cirrhosis using Fibrosis-4 (FIB-4) ≥ 3.25 and at least one risk factor for liver disease (e.g., obesity), and generate an age-stratified sample. Champions at four sites reviewed charts to confirm eligibility and contacted Veterans to offer further evaluation with elastography. Feasibility was defined as protocol implementation with completion of at least one elastography test and acceptability was defined based on Veteran- and clinician-reported surveys. Participation in the program, patient outcomes, adaptations to the protocol, and implementation barriers were also assessed. Results Four sites were able to implement the screening protocol. Adaptations included type of outreach (primary care vs. hepatology, phone vs. mail) and type of elastography used. One site chose to refer patients with clear evidence of cirrhosis directly to hepatology (n = 12) rather than to elastography. Key implementation barriers included staffing, primary care provider (PCP) comfort with interpreting and communicating results, and appointment availability during the COVID-19 pandemic. Of 488 patients whose charts were reviewed, 230 were excluded from outreach based on predefined criteria (e.g., advanced cancer, prior or current referral to hepatology). Champions and PCPs attempted to contact 165 of 246 Veterans who were deemed eligible for evaluation with elastography. Among 53 Veterans who completed elastography, 22 (42%) had findings consistent with significant fibrosis and were referred to hepatology. Clinicians and Veterans reported high acceptability of the program on surveys (80% of Veterans who completed survey). Conclusions This pilot demonstrated the feasibility, acceptability, and challenges of a multisite approach to cirrhosis screening.

INTRODUCTION:Metabolic dysfunction-associated steatotic liver disease (MASLD), an increasing public health concern, remains challenging to diagnose and risk-stratify. We assessed the (i) prevalence of MASLD risk factors among veterans in Veterans Health Administration (VA) care, (ii) factors associated with MASLD diagnosis, and (iii) associations between MASLD diagnosis and receipt of care. METHODS:Veterans with MASLD risk factors, including obesity, prediabetes, diabetes, or dyslipidemia, were identified using International Classification of Diseases-10 codes and followed in 2019-2022. Multivariable logistic regression and propensity score-adjusted models identified demographic and clinical characteristics associated with a diagnosis of MASLD or cirrhosis and receipt of elastography, specialty care for liver disease, VA weight management (MOVE!) participation, and glucagon-like peptide-1 (GLP-1) analog prescriptions. RESULTS:Among approximately 9 million veterans, 4,159,699 (45%) had risk factors for MASLD and were included in further analysis. MASLD or cirrhosis was diagnosed in 6% of the at-risk cohort. At-risk Veterans diagnosed with MASLD were younger with more metabolic risk factors, increased rates of alcohol use disorder, and higher FIB-4 scores and alanine transaminase values. Over 1-year follow-up, 6% engaged in MOVE!, 9% had specialty care for liver disease, 3% were prescribed GLP-1 analogs, and 2% underwent staging elastography. MASLD diagnosis was significantly associated with receipt of MOVE!, specialty care consultation, and GLP-1 analog prescription. DISCUSSION:Few at-risk Veterans carried an MASLD diagnosis or had undergone staging elastography. Because MASLD diagnosis was associated with linkage to hepatology care and weight loss therapy services, implementation of population screening and management services for MASLD is critically needed.

Background: Spontaneous bacterial peritonitis prophylaxis (SBPPr)-related practices are evolving, with recent studies showing almost half of potential subjects not being initiated on it. Aim: Determine practice dilemmas regarding SBPPr among US-based hepatology providers. Method: A questionnaire regarding primary and secondary SBPPr using quantitative and qualitative (open-ended) approaches was sent to US-based hepatology providers electronically. Results: 113 clinicians (86% physicians, 73% academic centers) responded. 54% started Primary and 72% secondary SBPPr in 50% of eligible patients. However, the issues related to antimicrobial resistance (AMR) and ineffectiveness lead to SBPPr usage variations and restrictions on a patient-specific basis. Most respondents (>70%) would withdraw/not initiate SBPPr with data regarding ineffectiveness and harms. Open-ended answers showed that most believed newer trials to reduce reliance on weaker older evidence are needed. Conclusion: A survey of US-based hepatologists demonstrates a major dilemma between usual care of initiating SBPPr versus not initiating/withdrawing SBPPr that needs newer randomized trials.

BACKGROUND:The Department of Veterans Affairs (VA) now offers eligible Veterans an urgent care benefit covering visits and 14-day prescriptions outside of VA. Prescriptions written and dispensed outside VA lack the clinical decision support of VA-issued prescriptions, raising concerns about safety and polypharmacy. To date, there has been limited analyses of prescribing patterns through the urgent care benefit. METHODS:We used a repeated cross-sectional design to examine Veterans who filled non-VA urgent care prescriptions from 07/30/2019 to 03/20/2023. Data were sourced from the Community Care Reimbursement System (CCRS), which tracks all VA-paid medications dispensed by non-VA pharmacies. We identified potentially noncompliant prescriptions as those not meeting VA urgent care benefit restrictions. We also identified prescriptions continued in VA as a "new VA medication" after 30-days from the urgent care fill. RESULTS:Overall, 83,862 Veterans received 271,476 non-VA urgent care prescriptions. Veterans' average age was 55.9, with 79.3 % male, 73.0 % White, 86.7 % non-Hispanic, and 41.4 % rural dwelling. Urgent care use increased from 341 prescription fills in March 2020 to 9738 in January 2023. Frequently filled prescriptions included antimicrobials (n = 114,492, 42.2 %) and hormones/synthetics/modifiers, like steroids (n = 44,457, 16.4 %). Potentially noncompliant prescriptions accounted for 9.3 %, with 6.7 % not on the urgent/emergent formulary and 2.6 % supplied for over 14 days. Over 70,704 (26.0 %) prescriptions were continued in VA post-urgent care visit, of which 15 % had no prior VA fill (i.e., new VA medication). Veterans with new continued VA prescriptions were more likely to be male (79.4 % vs. 73.9 %) and from urban areas (59.3 % vs. 57.5 %) (All P < .001). CONCLUSIONS:Veterans increasingly received non-VA prescriptions through urgent care centers in the community from 2019 to 2023, including drug classes of interest to VA due to potential risks of inappropriate prescribing (e.g., steroids) or drug interactions (e.g., antibiotics). The CCRS database can be integrated with other VA databases as a quality improvement tool to improve care coordination and drug safety. IMPLICATIONS:This evaluation highlights the need for improved clinical decision support for non-VA prescriptions and demonstrates the potential of integrated data systems to monitor and enhance medication safety and coordination within VA. LEVEL OF EVIDENCE:Cross-sectional analysis of national VA data.

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.

Introduction: Antibiotic overuse and subsequent antibiotic resistance lead to worse infection outcomes in cirrhosis. Secondary spontaneous bacterial peritonitis prophylaxis (SecSBBPr) is associated with higher SBP recurrence but impact on non-SBP infections is unclear. Methods: We studied patients with cirrhosis and SBP who were given SecSBPPr or not between 2009-2019 in two complementary national cohorts [Veterans affairs corporate data warehouse (VA-CDW) and non-VA TriNetX]. Development of total non-SBP infections and specifically urinary tract infections (UTI), bacteremia, pneumonia, and C.difficile using validated codes over 2 years was compared between those on SecSBPPr versus not. Multi-variable regression for non-SBP infections was performed. Results: VA-CDW: Of 4673 Veterans with index SBP, 2539 (54.3%) were started on SecSBPPr. 1406 (30.1%) developed non-SBP infections (13.5% UTI, 12.4% pneumonia, 8.5% bacteremia and 6.8% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.26, 95% CI:1.10-1.44, p<0.0001) and UTI (OR 1.21, 95% CI:1.01-1.45, p=0.036). TriNetX: Of 6708 patients with index SBP, 3261 (48.6%) were started on SecSBPPr. 1932 (28.8%) patients developed non-SBP infections (13.4% UTI, 12.9% pneumonia, 8.6% bacteremia and 5.9% C.difficile ). On multi-variable regression, SecSBPPr was significantly associated with any non-SBP infection (OR 1.33, 95% CI:1.12-1.59, p<0.0001), UTI (OR 1.35, 95% CI:1.07-1.71, p=0.010), pneumonia (OR 1.35, 95% CI:1.06-1.72, p=0.017), and bacteremia (OR 1.47, 95% CI:1.10-1.97, p=0.009). Conclusions: In two diverse US-based national cohorts of patients with cirrhosis and SBP, use of secondary SBP prophylaxis was associated with a higher risk of non-SBP infections , especially urinary tract infections.

Background Despite caring for conditions associated with high symptom burden and mortality, GI fellows rarely receive communication training. Aims To describe the development, implementation, and assessment of GITalk, a novel communication curriculum for gastroenterology (GI) fellows. Methods GITalk was designed to improve the skills needed to have effective serious illness conversations frequently encountered in clinical practice. Participants practiced encounters using two cases with simulated actors. One case involved delivering news that a patient with decompensated cirrhosis will no longer be a candidate for liver transplant, and the second case involved counseling the family of a patient with moderate to severe dementia on the risks and benefits of inserting a percutaneous feeding tube for artificial enteral nutrition. Results Annual training sessions were held for four consecutive years, representing a total of 23 GI fellows. Prior to participation in GITalk, few participants reported having had prior formal teaching in serious illness conversations. Paired sample t-tests showed that participants had significantly higher mean post-training preparedness scores compared to pre-training across all 9 survey questions. 91% of participants strongly agreed with the statement: “I would recommend this training to other fellows.” 78% strongly agreed with, “This training should be required of all GI fellows.” Conclusions Participants had little formal training in serious illness conversation prior to participation in GITalk. They reported substantial improvement in their self-assessed preparedness for discussing common clinical scenarios encountered in gastroenterology. GITalk can serve as a model for improvements in the Interpersonal and Communication Skills core competency for gastroenterology trainees.