The MISSION Act of 2018 expanded Veteran eligibility to seek care through community providers at VA expense (“VA community care”) with the goal of improving access to care, particularly for specialty services. Understanding trends in specialty referral volumes and the proportion of care outsourced to the community following MISSION implementation is critical to understanding where and how Veterans are accessing specialty care and whether MISSION is achieving its core policy goals. Describe changes in specialty referral volumes and the proportion of referrals outsourced to VA community care from FY 2019 to 2024, and concurrent changes in mean wait times. National, retrospective cohort study examining monthly referrals to 24 unique specialties. Veterans Health Administration (VA). VA-enrolled Veterans referred for outpatient specialty care. Monthly volume of specialty referrals in total and by category (medical, surgical, ancillary). Proportion of specialty care referred to VA community care in total, by category, and by individual specialty. Mean new patient wait time. The total monthly volume of specialty referrals increased from 1,163,172 to 1,657,504 (42.5

Background/Aims: While commonly prescribed in patients with inadequate bowel preparation, split-dose, 2-day bowel preparation (2DBP) with 8 L of polyethylene glycol-electrolyte lavage solution (PEG-ELS) has unknown effectiveness and safety. Study Aims: To assess the effectiveness of a split-dose, 8 L-2DBP in patients with a prior failed bowel preparation. Methods: We retrospectively identified all outpatients with inadequate bowel preparation on index colonoscopy with a 1-day split-dose prep who had repeat colonoscopy with a split-dose 2DBP (2015 to 2021) at a single Veterans Affairs medical center. We then assessed adequate bowel preparation (outcome), defined as excellent/good or Boston Bowel Prep Score (BBPS) 6 or greater, with a score of 2 in all colon segments. We also collected data on patient factors associated with inadequate preparation. Logistic regression was used to identify associations between these factors and inadequate preparation after split-dose 2DBP. All patient records were manually reviewed to identify potential adverse effects resulting in emergency room presentation. Results: Among 400 patients given 2DBP, 83.5% (95% CI: 79.5%-87.0%) achieved an adequate preparation. In multivariable analysis, a higher CCI (OR: 1.14, 95% CI: 1.04-1.25), opioid use (OR: 1.97, 95% CI: 1.03-3.77), and rural home address (OR: 1.87, 95% CI: 1.01-3.46) were associated with inadequate bowel preparation. No attributable adverse events were recorded. Conclusion: In this difficult-to-prep population, split-dose 2DBP is effective in more than 80% of patients without evidence of severe adverse events. This intensive prep was less effective in patients with greater comorbidity burden, opioid use, or a rural home address.

OBJECTIVES:Bidirectional endoscopy is recommended for new-onset iron deficiency anemia (IDA), given the risk of gastrointestinal (GI) cancer. The rate of endoscopic assessment in younger patients is unknown. STUDY DESIGN:Retrospective cohort study. METHODS:We assessed US veterans younger than 45 years with new-onset IDA and their outcomes of endoscopy within 1 year. RESULTS:There was a low rate of bidirectional endoscopy in this population (9.58% within 1 year). Predictors of undergoing any endoscopic evaluation included male sex (OR, 5.13; 95% CI, 4.55-5.78) and hemoglobin level (OR, 0.76 per 1-unit increase; 95% CI, 0.72-0.80). CONCLUSIONS:Given low current rates of bidirectional endoscopic evaluation in this population, implementation of bidirectional endoscopy in all individuals with IDA would require significantly increased resources. Further study of this population is needed to determine the impact of the 2020 American Gastroenterological Association guidelines on endoscopic use and GI cancer diagnoses.

New onset iron deficiency anemia (IDA) may indicate undiagnosed gastrointestinal (GI) cancer. Current guidelines strongly recommend colonoscopy and upper endoscopy (bidirectional endoscopy) for new onset IDA in men and postmenopausal women. In younger women, guidelines conditionally recommend bidirectional endoscopy, as IDA can occur from benign menstrual blood loss. Given rising rates of GI cancers in younger individuals, disregarding IDA in premenopausal women could inadvertently lead to delayed diagnoses of GI cancer. We assessed the likelihood of GI cancer in a national cohort of Veterans with new onset IDA by age and sex, using common clinical cutoffs. We conducted a retrospective cohort study in the Veterans Health Administration (VA). We identified regular users of VA primary care (≥1 primary care visit every 2 years over a 5-year period) who developed a new anemia (hemoglobin <12 g/dL for women, <13 g/dL for men), and who had a ferritin within 1 year. We defined IDA as ferritin <45 ng/ml and varied this definition in sensitivity analysis. We identified luminal GI cancers (esophageal, gastric, small intestine, colon, rectum) diagnosed within 1 year of incident anemia by the VA cancer registry. We calculated the odds ratio (OR) of IDA and a GI cancer diagnosis in the overall cohort, stratified by age and sex. 308,250 individuals met inclusion criteria, with 18,672 (6.1%) women and 289,578 (93.9%) men. 94,713 (30.7%) had IDA, and 33,711 (10.9%) were <50 years old. 3,035 GI cancers were diagnosed within 1 year of incident anemia (0.98%), the majority of which were colon cancers (n=1835, 60.5%). The odds of cancer were significantly higher in those with IDA versus non-IDA (OR 4.47, 95% CI: 4.14-4.82). For women with IDA age ≥ 50 compared to those < age 50, the OR of GI cancer in 1 year was 6.62 (95% CI: 3.54-12.36). In those < age 50 with IDA, men had an OR of GI cancer in 1 year of 9.74 compared to women (95% CI: 5.45-17.40). In those age ≥ 50 with IDA, men had an OR of GI cancer of 2.24 compared to women (95% CI: 1.64-3.05). In sensitivity analysis, lowering the ferritin cutoff to 10 ng/ml did not change the directionality of these relationships. Women age < 50 with new onset IDA were substantially less likely to develop GI cancer than comparable age men and older women. These findings support current guidelines, which strongly recommend bidirectional endoscopy in men and postmenopausal women and conditionally recommend endoscopy in premenopausal women. At the same time, clinicians should carefully assess for the presence / absence of symptoms that point to GI tract blood loss in premenopausal women. Additionally, future work should explore the role of computational methods and the electronic health record to leverage data from longitudinal complete blood counts (CBCs), moving beyond simple ferritin cutoffs. Andrew J. Read, Sarah L. Krein, Tony Van, Kennedy Dubose, Jennifer Burns, Akbar K. Waljee, Sameer D. Saini. Risk of gastrointestinal cancer by sex and age in U.S. veterans with new-onset iron deficiency anemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 3596.

Importance Continuing prostate-specific antigen (PSA) screening after age 70 years might benefit men at high risk of prostate cancer–specific mortality (PCSM) or metastatic prostate cancer (mPCa), but the relative value of clinical factors (race and ethnicity, competing mortality, and PSA history) in identifying men at higher vs lower risk is unknown. Objective To examine the value of PSA levels, race and ethnicity, and competing mortality in risk stratification for PCSM and mPCa in men after age 70 years. Design, Setting, and Participants In this cohort study, clinical data of all men receiving health care through the Veterans Health Administration who turned age 70 years between 2008 and 2020 and had a normal screening PSA value between age 65 and 69 years (<4 ng/mL [baseline PSA]) and no prior history of prostate cancer or biopsy were examined. The data cutoff date was December 26, 2023. Exposure The most recent screening PSA value from age 65 to 69 years, self-reported race and ethnicity, and competing mortality risk derived from a machine learning model. Main Outcome and Measures The 10-year absolute risk of PCSM and mPCa were determined using regression modeling. Results The cohort included 921 609 men who turned 70 years between 2008 and 2020; 11% of whom self-reported as Black and 82% as White race. Between age 65 and 70 years, 45% of patients had a baseline PSA of less than 1.00 ng/mL, and 32% had a baseline PSA of 1.00 to 1.99 ng/mL. Most patients (87%) continued to undergo screening past age 70 years, with little variation by competing mortality risk or race and ethnicity. The 10-year cumulative incidence of PCSM was 0.26% overall, and 95% of men had a 10-year risk less than 0.73%. Higher baseline PSA level between age 65 and 69 years was associated with 10-year PCSM risk (0.79% for 3.00-3.99 ng/mL vs 0.10% for 0.20-0.99 ng/mL), race and ethnicity (0.36% for Black vs 0.25% for White), and competing mortality (0.24% for the highest quintile vs 0.21% for the lowest quintile). Similar results were found for mPCa. Low PSA (0.20-0.99 ng/mL) was associated with very low PCSM and mPCa risk, even among Black men in the healthiest quintile of competing mortality risk (10-year PCSM risk, 0.08% [95% CI, 0.01%-0.44%]; 10-year mPCa risk 0.24% [95% CI, 0.10%-0.52%]). Conclusions and Relevance In this cohort study, the findings suggest that most men receiving care through the VHA continue PSA screening after age 70 years despite low absolute 10-year PCSM risks. The PSA values from age 65 to 69 years may be highly informative for adverse prostate cancer outcomes after age 70 years, with a PSA less than 1 ng/mL associated with a very low risk of long-term PCSM and mPCa.

Glucocorticoids are used commonly despite their toxicity and availability of effective alternatives. Prior claims-based studies evaluating effect of clinician specialty on glucocorticoid prescribing do not examine how facility-level resources affect prescribing patterns. We aim to describe the effect of facility complexity and clinician specialty on oral glucocorticoid prescribing in the general population. This is a national cross-sectional study of Veterans prescribed oral glucocorticoids during 2021-2022. We defined glucocorticoid use as ≥1 outpatient pharmacy claim for oral glucocorticoids, and prolonged use as ≥30 days' supply dispensed within 365 days. We defined complexity, rurality, and region using VHA operational metrics, and clinician specialty using NUCC taxonomy codes. We descriptively evaluated demographics, comorbidities, and healthcare utilization stratified by glucocorticoid use. We calculated the proportion of users and prolonged users at each facility, stratified by complexity, rurality, and region. We calculated the proportion of glucocorticoid prescriptions by clinician specialty. For three high-prescribing specialties, we calculated the facility-level proportion of glucocorticoid prescriptions by complexity designation. Here we show that among 5,729,134 patients at 124 facilities, a mean of 12.1% (SD 3.5%) are glucocorticoid users; 2.1% (SD 0.5%) were prolonged users. Rates of use and prescribing vary substantially within and across facility complexity designations. Family practice represents 18.8% of glucocorticoid-prescribing clinicians but prescribes 26.3% of filled prescriptions. Family practice displays higher prescribing at lower-complexity sites. In this large national population, overall and prolonged glucocorticoid use are common and prescribing patterns vary by clinician type and complexity designation. Clinician-facing interventions to address knowledge gaps, incentivize non-glucocorticoid treatments, or facilitate specialty care access may reduce overuse among high-prescribing clinicians.

Prostate-specific membrane antigen (PSMA) PET was approved by the U.S. Food and Drug Administration in 2020 for the staging of newly diagnosed prostate cancer, yet rates of adoption and real-world positivity rates are unknown. We characterized patients undergoing PSMA PET staging and describe positive findings in a large national cohort. Methods: We identified all newly diagnosed prostate cancer patients in the national Veterans Health Administration from June 2020 to August 2023. Demographics, staging imaging reports, and cancer-related information were obtained from electronic medical record data. To assess positive findings, we chart-reviewed 1,994 patients (n = 657 low to intermediate risk) with staging PSMA PET reports available. Results: Among 31,838 patients with newly diagnosed prostate cancer, 4,538 (14%) underwent PSMA staging. Use of PSMA staging increased rapidly from near 0 in early 2021 to approximately 70% of patients with high- or very-high-risk disease by August 2023. Among patients who were N0/M0 by conventional imaging, PSMA PET positivity rates (N1 or M1) were 5.9% for favorable intermediate risk, 8.2% for unfavorable intermediate risk, 14% for high risk, and 34% for very high risk. Conclusion: PSMA PET staging for newly diagnosed prostate cancer increased rapidly in the Veterans Health Administration. Positivity rates were less than 10% in this large intermediate-risk cohort. These data confirm the utility of PSMA PET staging in high-risk disease and suggest that additional study is needed to refine patient selection in intermediate-risk disease.

BACKGROUND:The use of hot biopsy forceps (with electrocautery) is no longer routinely recommended given increased complications compared to cold biopsy forceps (without electrocautery). It is unknown how often the technique is currently used in the United States (U.S.) or how its usage has changed over time. AIM:To characterize the use of hot biopsy forceps by U.S. Medicare providers over time, identify provider characteristics of those who more commonly perform this technique, and determine if there are regional differences in use of this technique within the U.S. METHODS:We performed a retrospective cross-sectional study using U.S. Medicare summary data from 2000 to 2019 to analyze the frequency of cold and hot biopsies. We used detailed provider and state summary files to characterize providers' demographics, including geographic region, to identify regional variation in use of these techniques, and identify factors associated with use of hot biopsy forceps from 2012 to 2019. RESULTS:The hot biopsy forceps technique peaked in 2003 (412,165/year) and declined to 108,232/year in 2019, while the cold biopsy forceps technique increased from 482,862/year in 2000 to 1,533,558/year in 2019. Use of hot biopsy forceps was more common by non-gastroenterologists and in rural practice settings. In addition, there was up to 50-fold difference in utilization in these techniques between states (on a population normalized basis), with the highest rate of use in the southeastern U.S. CONCLUSION:Variation in the use of hot biopsy forceps by region and provider suggests a potential area for quality improvement given the comparative advantages of the cold biopsy forceps technique. De-implementation of an existing endoscopic practice may require different approaches than implementation of a new practice.

350 Background: Prostate-specific membrane antigen (PSMA) PET/CT has become a common initial staging modality for localized prostate cancer due to its increased sensitivity and specificity over conventional staging. However, the causal impact of widespread PSMA staging on initial prostate cancer treatments has not been described. Methods: We used electronic medical record data from a national, diverse health system (Veterans Health Administration) to emulate a randomized controlled trial in which patients with newly diagnosed conventionally localized unfavorable intermediate, high, and very high-risk prostate cancer were allocated to either upfront PSMA staging or conventional imaging with technetium-99 bone scan and pelvic CT or MRI. Primary outcomes included the use of any androgen deprivation therapy (ADT), advanced androgen receptor pathway inhibitors (ARPIs), radiotherapy, and radical prostatectomy assessed in the year after diagnosis. We used the cloning, censoring, and weighting technique to estimate the causal effect of PSMA staging, controlling for potential confounders. In exploratory analyses, we extracted radiographic stage from PSMA reports using a natural language processing algorithm and assessed the influence of PSMA findings (N0M0, N1M0, or M1) on treatment patterns. Results: 9,049 patients met criteria for inclusion in the emulated trial, of whom 35% underwent PSMA staging and 46% underwent bone scan. In the emulated trial, PSMA staging was associated with higher rates of any ADT usage relative to conventional staging (adjusted hazard ratio [aHR] 1.26, 95% confidence interval [CI] 1.19-1.44), higher ARPI usage (aHR 1.52, 95% CI 1.33-1.78), lower prostatectomy usage (aHR 0.69, 95% CI 0.56-0.83), and no effect on radiotherapy usage (aHR 1.10, 95% CI 0.99-1.25). Compared to patients with PSMA N0M0, ARPI usage was higher in patients with N1M0 (aHR 6.87, 95% CI 5.41-8.73) and M1 (aHR 10.13, 95% CI 8.16-1.2.58). Patients with N1M0 or M1 disease were less likely to undergo prostatectomy compared to N0M0. Similar patterns were seen in subgroup analyses within risk groups. Conclusions: In this emulated randomized trial, PSMA staging of localized prostate cancer was associated with increased rates of any ADT and ARPI use and lower rates of prostatectomy relative to conventional staging. The implications of these treatment changes on oncologic outcomes require further study.

OBJECTIVES:The COVID-19 pandemic stimulated an unprecedented expansion in use of video and telephone visits (televisits) for routine specialty care as a substitute for in-person clinic visits. However, the sustainability of televisit use for specialty care delivery following the pandemic is unclear. STUDY DESIGN/METHODS:In this descriptive, retro-spective study of national Veterans Health Administration (VHA) data, we assessed total outpatient visit volume by month in 9 specialties (cardiology, dermatology, eye care, gastroenterology [GI]/hepatology, neurosurgery, orthopedics, podiatry, substance use disorder [SUD], and urology) at all VHA facilities in the US between January 2019 (pre-COVID-19) and September 2023 (representing late phases of health system recovery post COVID-19). We also categorized outpatient visits by modality (in person, telephone, video) and assessed time trends in the proportion of total outpatient visits in each specialty delivered by televisit. Descriptive statistics were used to summarize the study findings. RESULTS:Although total visit volumes in most VHA specialties had returned to pre-COVID-19 baselines by the end of the study period, they did not fully rebound in others, suggesting persistent care gaps. Televisit use increased from a mean of 7% in quarter 1 (Q1) 2019 to 54% in Q2 2020, then decreased modestly to 27% of all specialty visits by Q3 2023. The specialties with the highest sustained televisit use in Q3 2023 were SUD and GI, despite restored in-person visit availability. The use of telephone visits exceeded the use of video visits throughout the study period. CONCLUSIONS:Our findings suggest that televisits will likely remain an important visit modality for patients in the postpandemic era.

Many patients receiving anticoagulants take antiplatelet medications unnecessarily and without gastroprotection, increasing the risk of gastrointestinal bleeding. To evaluate the effectiveness of a multicomponent intervention—clinician notification with nurse facilitation (CNNF)—in reducing high-risk use of antiplatelet medications in patients taking warfarin without a proton pump inhibitor (PPI). For patients in the CNNF group, nurses sent electronic messages to clinicians identifying patients with high-risk antiplatelet use, recommending consideration of either antiplatelet discontinuation or PPI initiation, and offering to facilitate any medication changes. The primary outcome was the percentage of patients who self-reported either discontinuing antiplatelet therapy or initiating a PPI at 7 to 10 weeks. The secondary outcome was the percentage of patients with a documented clinician recommendation to make such a medication change. Among 220 patients, CNNF was associated with increased odds of discontinuing antiplatelet therapy or initiating a PPI in the intention-to-treat analysis (adjusted odds ratio [aOR] 5.76, 95% CI 2.54, 13.05). The effect was stronger in a modified completer analysis (n = 126, aOR 43.6, 95% CI 6.56, 289.88). The intervention was also associated with increased odds of a clinician recommendation for a medication change (75/110 [68.2%] versus 1/110 [0.9%], log aOR 19.86, 95% CI 10.63, 29.09). Surgeons and proceduralists were less likely to recommend medication changes relative to other clinicians (log aOR −16.08, 95% CI −23.34, −8.82). The multicomponent intervention effectively led to antiplatelet discontinuation or PPI initiation in patients initially prescribed warfarin-antiplatelet therapy without gastroprotection.

Abstract Background Many men with prostate cancer will be exposed to androgen deprivation therapy (ADT). While evidence-based ADT use is common, ADT is also used in cases with no or limited evidence resulting in more harm than benefit, i.e., overuse. Since there are risks of ADT (e.g., diabetes, osteoporosis), it is important to understand the behaviors facilitating overuse to inform de-implementation strategies. For these reasons, we conducted a theory-informed survey study, including a discrete choice experiment (DCE), to better understand ADT overuse and provider preferences for mitigating overuse. Methods Our survey used the Action, Actor, Context, Target, Time (AACTT) framework, the Theoretical Domains Framework (TDF), the Capability, Opportunity, Motivation–Behavior (COM-B) Model, and a DCE to elicit provider de-implementation strategy preferences. We surveyed the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on the likelihood of stopping overuse as ADT monotherapy for localized prostate cancer (“yes”/“probably yes,” “probably no”/“no”), and characterized corresponding Likert scale responses to seven COM-B statements. We used multivariable regression to identify associations between stopping ADT overuse and COM-B responses. Results Our survey was completed by 84 respondents (13% response rate), with 27% indicating “probably no”/“no” to stopping ADT overuse. We found differences across respondents who said they would and would not stop ADT overuse in demographics and COM-B statements. Our model identified 2 COM-B domains (Opportunity–Social, Motivation–Reflective) significantly associated with a lower likelihood of stopping ADT overuse. Our DCE demonstrated in-person communication, multidisciplinary review, and medical record documentation may be effective in reducing ADT overuse. Conclusions Our study used a behavioral theory-informed survey, including a DCE, to identify behaviors and context underpinning ADT overuse. Specifying behaviors supporting and gathering provider preferences in addressing ADT overuse requires a stepwise, stakeholder-engaged approach to support evidence-based cancer care. From this work, we are pursuing targeted improvement strategies. Trial registration ClinicalTrials.gov, NCT03579680