BACKGROUND: Influenza may contribute to coronary/cerebrovascular events and exacerbate underlying conditions.
METHODS: We used self-controlled case series (SCCS) design to analyze data from US Veterans ≥18 years with coronary/cerebrovascular or exacerbation event +/-1 year of lab-confirmed influenza (LCI) during 2010-2018. We estimated the incidence ratio (IR) (95% CI) of the event for risk interval (Days 1-7 post-LCI) versus control interval (all other times +/-1 year of LCI) with fixed-effects conditional Poisson regression. We included biomarker data for mediation analysis.
RESULTS: We identified 3439 episodes with coronary/cerebrovascular-related hospitalizations. IRs (95% CI) for LCI risk versus control interval were STEMI 0.6 (0.1, 4.4), NSTEMI 7.3 (5.8, 9.2), ischemic stroke 4.0 (3.0, 5.4), hemorrhagic stroke 6.2 (3.4, 11.5), and coronary spasm 1.3 (0.5, 3.0). IR significantly increased for NSTEMI and ischemic stroke among those ≥ 65 years. IR for NSTEMI and ischemic stroke dropped 26% and 10%, respectively, when white blood cell (WBC) and platelet count were considered. LCI was significantly associated with exacerbation of preexisting asthma, chronic obstructive pulmonary disease, and congestive heart failure.
CONCLUSIONS: We found significant association between LCI and hospitalization for NSTEMI, ischemic stroke, and hemorrhagic stroke, the latter possibly due to unaccounted time-varying confounding in SCCS design.

BACKGROUND: Use of participatory research methods is increasing in research trials. Once partnerships are established with end-users, there is less guidance about processes research teams can use to successfully incorporate end-user feedback. The current study describes the use of a brief reflections process to systematically examine and evaluate the impact of end-user feedback on study conduct.
METHODS: The Comparative Effectiveness of Trauma-Focused and Non-Trauma- Focused Treatment Strategies for PTSD among those with Co-Occurring SUD (COMPASS) study was a randomized controlled trial to determine the effectiveness of trauma-focused psychotherapy versus non-trauma-focused psychotherapy for Veterans with co-occurring posttraumatic stress disorder and substance use disorder who were entering substance use treatment within the Department of Veterans Affairs. We developed and paired a process of \"brief reflections\" with our end-user engagement methods as part of a supplemental evaluation of the COMPASS study engagement plan. Brief reflections were 30-minute semi-structured discussions with the COMPASS Team following meetings with three study engagement panels about feedback received regarding study issues. To evaluate the impact of panel feedback, 16 reflections were audio-recorded, transcribed, rapidly analyzed, and integrated with other study data sources.
RESULTS: Brief reflections revealed that the engagement panels made recommended changes in eight areas: enhancing recruitment; study assessment completion; creating uniformity across Study Coordinators; building Study Coordinator connection to Veteran participants; mismatch between study procedures and clinical practice; therapist skill with patients with active substance use; therapist burnout; and dissemination of study findings. Some recommendations positively impact study conduct while others had mixed impact. Reflections were iterative and led to emergent processes that included revisiting previously discussed topics, cross-pollination of ideas across panels, and sparking solutions amongst the Team when the panels did not make any recommendations or recommendations were not feasible.
CONCLUSIONS: When paired with end-user engagement methods, brief reflections can facilitate systematic examination of end-user input, particularly when the engagement strategy is robust. Reflections offer a forum of accountability for researchers to give careful thought to end-user recommendations and make timely improvements to the study conduct. Reflections can also facilitate evaluation of these recommendations and reveal end-user-driven strategies that can effectively improve study conduct.
BACKGROUND: ClinicalTrials.gov (NCT04581434) on October 9, 2020; https://clinicaltrials.gov/ct2/show/study/NCT04581434?term=NCT04581434&draw=2&rank=1 .

OBJECTIVE: Armed conflict remains a tragic feature of the modern world and so it is necessary to continue to study its health impacts. Even the study of historical conflicts is relevant given that certain health impacts are common to most wars e.g., post-traumatic stress disorder (PTSD).
METHODS: This study built on a previous quantitative analysis of a randomly selected group of 200 New Zealand veterans from the First World War (WWI). From this sample we selected 10 cases that illustrated particular themes around morbidity impacts.
RESULTS: The theme of severity of impacts was illustrated with a case who was severely wounded and died from suicide when back in New Zealand, and another case with severe PTSD. The theme of the high frequency of non-fatal conditions was revealed with cases illustrating new diagnoses (a case with n=8 diagnoses), hospitalisations for new conditions (n=6), non-fatal injury events (n=3) and for sexually transmitted infections (n=3). The theme of chronic debility as a consequence of various conditions was illustrated with cases who had suffered from being gassed or having gastroenteritis, malaria or pandemic influenza.
CONCLUSIONS: These 10 selected cases reiterate how severe and extensive the morbidity burden for military personnel in WWI could be. Also illustrated is how the morbidity could contribute to adverse impacts on some of their lives after returning to New Zealand.

BACKGROUND: To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.
METHODS: We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.
RESULTS: LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.
CONCLUSIONS: Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

OBJECTIVE: To conduct a business case analysis for Department of Veterans Affairs (VA) program STRIDE (ASsisTed EaRly MobIlization for hospitalizeD older VEterans), which was designed to address immobility for hospitalized older adults.
METHODS: This was a secondary analysis of primary data from a VA 8-hospital implementation trial conducted by the Function and Independence Quality Enhancement Research Initiative (QUERI). In partnership with VA operational partners, we estimated resources needed for program delivery in and out of the VA as well as national implementation facilitation in the VA. A scenario analysis using wage data from the Bureau of Labor Statistics informs implementation decisions outside the VA.
METHODS: This budget impact analysis compared delivery and implementation costs for two implementation strategies (Replicating Effective Programs [REP]+CONNECT and REP-only). To simulate national budget scenarios for implementation, we estimated the number of eligible hospitalizations nationally and varied key parameters (e.g., enrollment rates) to evaluate the impact of uncertainty.
METHODS: Personnel time and implementation outcomes were collected from hospitals (2017-2019). Hospital average daily census and wage data were estimated as of 2022 to improve relevance to future implementation.
RESULTS: Average implementation costs were $9450 for REP+CONNECT and $5622 for REP-only; average program delivery costs were less than $30 per participant in both VA and non-VA hospital settings. Number of walks had the most impact on delivery costs and ranged from 1 to 5 walks per participant. In sensitivity analyses, cost increased to $35 per participant if a physical therapist assistant conducts the walks. Among study hospitals, mean enrollment rates were higher among the REP+CONNECT hospitals (12%) than the REP-only hospitals (4%) and VA implementation costs ranged from $66 to $100 per enrolled.
CONCLUSIONS: STRIDE is a low-cost intervention, and program participation has the biggest impact on the resources needed for delivering STRIDE.
BACKGROUND: ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Our goal was to determine the prevalence of anxiety and depression in a sample of U.S. military veterans with type 2 diabetes and elevated diabetes distress (DD). Cross-sectional analyses were conducted. The association between DD and anxiety and depression was assessed with logistic regression. Almost 80% of persons with elevated DD had clinically significant anxiety or depression symptoms. The odds of depression and anxiety increased with DD severity. Given the large overlap of depression and anxiety with elevated DD, we recommend providers screen for all three conditions and, if positive, connect to resources for diabetes self-management and/or clinical treatment.

Music therapy is becoming increasingly prevalent in rehabilitation programs serving military and Veteran populations in the United States. Music therapy is integrated into interdisciplinary models and positioned to treat brain injury, post-traumatic stress disorder, and other psychological health conditions at military installations and Veteran medical centers nationwide. Phased group music therapy is delivered in a longitudinal treatment model to assist in the rehabilitation of service members and Veterans. Different phases of group music therapy are aligned with a treatment trajectory that exists on a clinic to community continuum to support recovery and reintegration. This article provides a description and case presentations of clinical programming. Information was accessed from patients\' electronic medical records, clinical documentation, therapist observation, and patient interviews. Interviews were transcribed and a content analysis was conducted by the authors. Emergent themes from the patient interviews included social relationships, community reintegration and transition, and post-military occupational success. Patients reported that group music therapy provided skill-building opportunities that were helpful for them during military service transitions, specifically active duty to Veteran status. Support skills included rapport-building and enhanced camaraderie. Furthermore, music therapy appeared to bolster peer connections through shared experiences, which decreased isolation, increased socialization, and supported reintegration.

Studies have raised concerns about possible inequities in the U.S. Department of Veterans Affairs (VA)\'s awards of disability for posttraumatic stress disorder (PTSD) to women. However, the diagnoses and opinions made by disability examiners have not been studied. A sample of 270 initial PTSD examination reports and corresponding VA decisions were studied. Compared to men, women veterans were as likely to be diagnosed with a service-related mental disorder, χ2(1, N = 270) = 2.31, p = .129, odds ratio (OR) = 1.79, 95% CI [0.84, 3.80], and be granted service-connection, χ2(1, N = 270) = 0.49, p = .483, OR = 1.28, 95% CI [0.65, 2.51]. Women veterans were considered to have more psychiatric symptoms, Z = -2.05, p = .041, r = .16, and more psychiatric impairment, Z = -2.48, p = .013, r = .20, but the percentage of disability awarded by the VA did not differ, χ2(1, N = 270) = 0.49, p = .483; OR = 1.28, 95% CI [0.65, 2.51]. Secondary analyses implicate the role of military sexual trauma and premilitary trauma in explaining sex differences in symptoms and impairment. The findings indicate that neither opinions by examiners nor corresponding decisions by the VA regarding service connection reflect a negative bias toward women veterans. Results indicate that unbiased examinations lead to equitable VA claims decisions for women veterans. Future studies of the VA PTSD disability program nationally, including examination procedures and VA policies and implementation, will promote equity for women veterans in the PTSD claims process.

UNASSIGNED: Chronic obstructive pulmonary disease (COPD) is a heterogeneous pulmonary disease affecting 16 million Americans. Individuals with COPD are susceptible to environmental disturbances including heat and cold waves that can exacerbate disease symptoms.
UNASSIGNED: Our objective was to estimate heat and cold wave-associated mortality risks within a population diagnosed with a chronic respiratory disease.
UNASSIGNED: We collected individual level data with geocoded residential addresses from the Veterans Health Administration on 377,545 deceased patients with COPD (2016 to 2021). A time stratified case-crossover study was designed to estimate the incidence rate ratios (IRR) of heat and cold wave mortality risks using conditional logistic regression models examining lagged effects up to 7 d. Attributable risks (AR) were calculated for the lag day with the strongest association for heat and cold waves, respectively. Effect modification by age, gender, race, and ethnicity was also explored.
UNASSIGNED: Heat waves had the strongest effect on all-cause mortality at lag day 0 [IRR: 1.04; 95% confidence interval (CI): 1.02, 1.06] with attenuated effects by lag day 1. The AR at lag day 0 was 651 (95% CI: 326, 975) per 100,000 veterans. The effect of cold waves steadily increased from lag day 2 and plateaued at lag day 4 (IRR: 1.04; 95% CI: 1.02, 1.07) with declining but still elevated effects over the remaining 7-d lag period. The AR at lag day 4 was 687 (95% CI: 344, 1,200) per 100,000 veterans. Differences in risk were also detected upon stratification by gender and race.
UNASSIGNED: Our study demonstrated harmful associations between heat and cold waves among a high-risk population of veterans with COPD using individual level health data. Future research should emphasize using individual level data to better estimate the associations between extreme weather events and health outcomes for high-risk populations with chronic medical conditions. https://doi.org/10.1289/EHP13176.

BACKGROUND: Availability of evidence-based practices (EBPs) is critical for improving health care outcomes, but diffusion can be challenging. Implementation activities increase the adoption of EBPs and support sustainability. However, when implementation activities are a part of quality improvement processes, evaluation of the time and cost associated with these activities is challenged by the need for a correct classification of these activities to a known taxonomy of implementation strategies by implementation actors.
METHODS: Observational study of a four-stage, stakeholder-engaged process for identifying implementation activities and estimating the associated costs.
RESULTS: A national initiative in the Veterans Health Administration (VHA) to improve Advance Care Planning (ACP) via Group Visits (ACP-GV) for rural veterans identified 49 potential implementation activities. Evaluators translated and reduced these to 14 strategies used across three groups with the aid of implementation actors. Data were collected to determine the total implementation effort and applied cost estimates to estimate the budget impact of implementation for VHA.
CONCLUSIONS: Recall bias may influence the identification of potential implementation activities.
CONCLUSIONS: This process improved understanding of the implementation effort and allowed estimation of ACP-GV \'s budget impact.
CONCLUSIONS: A four-stage, stakeholder-engaged methodology can be applied to other initiatives when a pragmatic evaluation of implementation efforts is needed.