There are few validated contextual measures predicting adoption of evidence-based programs. Variation in context at clinical sites can hamper dissemination. We examined organizational characteristics of Veterans Affairs hospitals implementing STRIDE, a hospital walking program, and characteristics\' influences on program adoption. Using a parallel mixed-method design, we describe context and organizational characteristics by program adoption. Organizational characteristics included: organizational resilience, implementation climate, organizational readiness to implement change, highest complexity sites versus others, material support, adjusted length of stay (LOS) above versus below national median, and improvement experience. We collected intake forms at hospital launch and qualitative interviews with staff members at 4 hospitals that met the initial adoption benchmark, defined as completing supervised walks with 5+ unique hospitalized Veterans during months 5 to 6 after launch with low touch implementation support. We identified that 31% (n = 11 of 35) of hospitals met adoption benchmarks. Seven percent of highest complexity hospitals adopted compared to 48% with lower complexity. Forty-three percent that received resources adopted compared to 29% without resources. Thirty-six percent of hospitals with above-median LOS adopted compared to 23% with below-median. Thirty-five percent with at least some implementation experience adopted compared to 0% with very little to no experience. Adopters reported higher organizational resilience than non-adopters (mean = 23.5 [SD = 2.6] vs 22.7 [SD = 2.6]). Adopting hospitals reported greater organizational readiness to change than those that did not (mean = 4.2 [SD = 0.5] vs 3.8 [SD = 0.6]). Qualitatively, all sites reported that staff were committed to implementing STRIDE. Participants reported additional barriers to adoption including challenges with staffing and delays associated with hiring staff. Adopters reported that having adequate staff facilitated implementation. Implementation climate did not have an association with meeting STRIDE program adoption benchmarks in this study. Contextual factors which may be simple to assess, such as resource availability, may influence adoption of new programs without intensive implementation support.

UNASSIGNED: Open burn pits have commonly been used for waste disposal by the US military but have not been systematically investigated as an independent risk factor for headache disorders.
UNASSIGNED: To evaluate the association between exposure to open burn pits and incidence of headache and migraine.
UNASSIGNED: This retrospective cohort study used data from the Veterans Health Administration Headache Cohort along with data from the US Department of Defense and the Airborne Hazards and Open Burn Pit (AH&OBP) Registry to assess registry participants with potential exposure to open burn pits in the Veterans Health Administration from April 1, 2014, through October 31, 2022. Participants were included by linking data from the AH&OBP Registry to their US Department of Defense and Veterans Health Administration electronic health records. Those with preexisting headache were removed from the analytic sample. The analysis was conducted between November 1, 2022, and January 31, 2024.
UNASSIGNED: Open burn pit exposure composite variables based on the registry questionnaire were examined, specifically being near open burn pits, days near open burn pits, and having open burn pit duties.
UNASSIGNED: Primary incident outcomes included medically diagnosed headache disorders and medically diagnosed migraine.
UNASSIGNED: The analytic sample included 247 583 veterans (mean [SD] age, 27.9 [7.7] years; 222 498 [89.9%] male). After covariates were controlled for at baseline, participants who were near an open burn pit with open burn pit duties had the highest adjusted odds of medically diagnosed headache disorders (adjusted odds ratio [AOR], 1.59; 95% CI, 1.46-1.74), migraine (AOR, 1.60; 95% CI, 1.43-1.79), and self-reported disabling migraine (AOR, 1.93; 95% CI, 1.69-2.20) compared with those without exposure. The 2 highest quartiles of cumulative burn pit exposure (290-448 days and >448 days) had significantly higher adjusted odds of medically diagnosed headache (290-448 days: AOR, 1.20; 95% CI, 1.09-1.31; >448 days: AOR, 1.55; 95% CI, 1.41-1.70) and migraine (290-448 days: AOR, 1.19; 95% CI, 1.07-1.34; >448 days: AOR, 1.48; 95% CI, 1.32-1.65).
UNASSIGNED: In this cohort study, a dose-dependent association existed between open burn pit exposure and medically diagnosed headache and migraine. These new data identify potentially important associations between open burn bit exposure and new-onset headache among service personnel as well as a possible health condition that may be encountered more frequently in Veterans Health Administration facilities during mandatory screening for military exposures.

BACKGROUND: Veterans with substance use disorder (SUD) are at high risk for cognitive problems due to neurotoxic effects of chronic drug and alcohol use coupled in many cases with histories of traumatic brain injury (TBI). These problems may in turn result in proneness to SUD relapse and reduced adherence to medical self-care regimens and therefore reliance on health care systems. However, the direct relationship between cognitive function and utilization of Veterans Health Administration (VHA) SUD and other VHA health care services has not been evaluated. We sought initial evidence as to whether neurocognitive performance relates to repeated health care engagement in Veterans as indexed by estimated VHA care costs.
METHODS: Neurocognitive performance in 76 Veterans being treated for SUD was assessed using CNS-Vital Signs, a commercial computerized cognitive testing battery, and related to histories of outpatient and inpatient/residential care costs as estimated by the VHA Health Economics Resource Center.
RESULTS: After controlling for age, an aggregate metric of overall neurocognitive performance (Neurocognition Index) correlated negatively with total VHA health care costs, particularly with SUD-related outpatient care costs but also with non-mental health-related care costs. Barratt Impulsiveness Scale scores also correlated positively with total VHA care costs.
CONCLUSIONS: In Veterans receiving SUD care, higher impulsivity and lower cognitive performance were associated with greater health care utilization within the VHA system. This suggests that veterans with SUD who show lower neurocognitive performance are at greater risk for continued health problems that require healthcare engagement. Cognitive rehabilitation programs developed for brain injury and other neurological conditions could be tried in Veterans with SUD to improve their health outcomes.

The United States Veterans Affairs (VA) Health Care System has a strong history of conducting impactful oncology randomized clinical trials (RCTs). We developed a phase II/III RCT to test the use of metastasis-directed therapy in Veterans with oligometastatic prostate cancer (OMPC)-the first VA RCT in OMPC that leverages novel imaging and advanced radiotherapy techniques. To accomplish this, we developed a clinical trial network to conduct the study. In this manuscript, we describe several challenges we encountered in study development/conduct and our strategies to address them, with the goal of helping investigators establish robust study networks to conduct clinical trials. In the study start-up, we encountered challenges in timely site activation, and leveraged project management to maximize efficiency. Additionally, there were several changes in the clinical paradigms in imaging and treatment that led to protocol amendments to ensure maximum equipoise, recruitment, and impact of the study. Specifically, we amended the trial to add de novo OMPC patients (from initially only recurrent OMPC) and expanded the study to allow up to 10 metastases (from initially five). Finally, in order to maintain local study team engagement, we developed initiatives to maximize collaboration and add value to the overall clinical program through study participation.

BACKGROUND: The Diabetes Prevention Program (DPP) is a nationally disseminated lifestyle intervention shown to prevent type 2 diabetes (diabetes). However, enrollment in the program remains variable. We sought to identify patient characteristics associated with enrollment in a virtual DPP program among women Veterans to inform ongoing diabetes prevention efforts.
METHODS: We conducted a retrospective analysis of 2021-2024 Department of Veterans Affairs (VA) data collected through the VA Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 Program, an effectiveness-implementation trial to expand access to preventative health services for women Veterans. We included women meeting DPP eligibility criteria (BMI ≥ 25 kg/m2 [or ≥ 23 if Asian] with ≥ 1 risk factor for diabetes [e.g., prediabetes]) who received care at six VA sites implementing virtual DPP. We used logistic regression to examine the association between DPP enrollment and prior use of VA preventive services for weight management or diabetes prevention including the VA MOVE! clinic, Whole Health visits, nutrition visits, weight loss medications, and/or metformin. We adjusted for sociodemographic factors, comorbidities, number of DPP recruitment contacts, and site.
RESULTS: A total of 1473 women Veterans received DPP outreach. On average, their age was 53 years (range 20-96), BMI 34 kg/m2, HbA1c 5.9%, 0.7% were Asian, 44% Black, 2% Hispanic, and 44% White. In our adjusted models, prior use of VA preventative services was not significantly associated with DPP enrollment. Younger women (OR:0.97, p = 0.002) and those who received more recruitment contacts (OR:2.63, p < 0.001), were significantly more likely to enroll in DPP. Women with housing instability were significantly less likely to enroll (OR:0.44, p = 0.029).
CONCLUSIONS: We found no difference in women Veterans\' enrollment in DPP based on prior use of VA weight management and prevention services. Frequency of outreach by VA sites may increase engagement in lifestyle interventions. Virtual DPP may support engagement in preventive lifestyle interventions for diverse groups of women Veterans, as a first program or as a complement to other VA services.
BACKGROUND: ClinicalTrials.gov, NCT05050266. Registered on 20 September 2021.

 Post-traumatic stress disorder (PTSD) may be a risk factor for Parkinson\'s disease (PD). We examined the relation between PTSD and PD in a cohort of 158,122 Veterans who had any Veterans Health Administration (VHA) or Medicare health care utilization between 10/1/1999- 2/17/2021. Using a nested case-control design we matched 10 controls to each Veteran with PD by sex, race, and rank. In conditional logistic regression models adjusted for camp and smoking, a PTSD diagnosis was significantly associated with PD (OR = 1.35; p = 0.0002); odds were higher if PTSD was coded before PD (OR = 1.53, p < 0.0001). PTSD may be a risk factor for PD.

OBJECTIVE: To identify the needs of caregivers of hospitalised adults with dementia in the hospital and during care transitions.
METHODS: Pragmatic qualitative inquiry with semi-structured interviews.
METHODS: Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, USA.
METHODS: 12 family caregivers (family member (n=11); friend (n=1)) and 15 health professionals (hospital medicine physicians (n=4), inpatient nurse case managers (n=2), social workers (n=4), outpatient geriatrics providers (n=2), a primary care provider (n=1), geriatric psychiatrists (n=2)) were interviewed. Caregivers were recruited while their care recipient was hospitalised and were interviewed at least 2 weeks after the care recipient was discharged from the hospital. Health professionals were eligible for the study if they provided care to patients with dementia in the inpatient or outpatient setting.
RESULTS: Four recommendations emerged from the analysis: (1) engage caregivers as partners in the care team, (2) provide dementia-specific information and training, (3) connect caregivers to home and community-based services and (4) provide care navigation and support for the caregiver posthospitalisation.
CONCLUSIONS: Hospital care transitions are challenging for caregivers of hospitalised adults living with dementia. Care transition interventions designed to support caregivers with tailored, dementia-specific information and services are needed.

BACKGROUND: Research suggests an association between COVID-19 infection and certain financial hardships in the shorter term and among single-state and privately insured samples. Whether COVID-19 is associated with financial hardship in the longer-term or among socially vulnerable populations is unknown. Therefore, we examined whether COVID-19 was associated with a range of financial hardships 18 months after initial infection among a national cohort of Veterans enrolled in the Veterans Health Administration (VHA)-the largest national integrated health system in the US. We additionally explored the association between Veteran characteristics and financial hardship during the pandemic, irrespective of COVID-19.
METHODS: We conducted a prospective, telephone-based survey. Out of 600 Veterans with COVID-19 from October 2020 through April 2021 who were invited to participate, 194 Veterans with COVID-19 and 194 matched comparators without a history of infection participated. Financial hardship outcomes included overall health-related financial strain, two behavioral financial hardships (e.g., taking less medication than prescribed due to cost), and seven material financial hardships (e.g., using up most or all savings). Weighted generalized estimating equations were used to estimate risk ratios (RR) and 95% confidence intervals (CI) of financial hardship by COVID-19 status, and to assess the relationship between infection and Veteran age, VHA copay status, and comorbidity score, irrespective of COVID-19 status.
RESULTS: Among 388 respondents, 67% reported at least one type of financial hardship since March 2020, with 21% reporting behavioral hardships and 64% material hardships; 8% reported severe-to-extreme health-related financial strain. Compared with uninfected matched comparators, Veterans with a history of COVID-19 had greater risks of severe-to-extreme health-related financial strain (RR: 4.0, CI: 1.4-11.2), taking less medication due to cost (RR: 2.9, 95% CI: 1.0-8.6), and having a loved one take time off work to care for them (RR: 1.9, CI: 1.1-3.6). Irrespective of COVID-19 status, Veterans aged < 65 years had a greater risk of most financial hardships compared with Veterans aged ≥ 65 years.
CONCLUSIONS: Health-related financial hardships such as taking less medication due to cost and severe-to-extreme health-related financial strain were more common among Veterans with a history of COVID-19 than among matched comparators. Strategies are needed to address health-related financial hardship after COVID-19.
BACKGROUND: NCT05394025, registered 05-27-2022.

BACKGROUND: The responsibility of care for Veterans and Service Members (V/SMs) with traumatic brain injury (TBI) often defaults to informal family caregivers. Caregiving demands considerable knowledge, skill, and support to facilitate the health and well-being of V/SMs and themselves. Persistent and common TBI caregiver issues include strain, depression, and anxiety. While evidence-based, brief interventions have been developed and implemented for family caregivers in Veteran neurodegenerative populations, few interventions have been developed, adapted, or tested to support the unique needs of caregivers of V/SMs with TBI.
OBJECTIVE: This study will adapt and test an evidence-based, personalized, 6-session telehealth caregiver intervention, \"Resources for Enhancing All Caregivers\' Health\" (REACH), to meet the unique needs of caregivers of V/SMs with TBI. If successful, a community-based participatory research team will develop an implementation plan to roll out REACH TBI across the national Veterans Affairs Polytrauma System of Care.
METHODS: This mixed methods, crossover waitlist control clinical trial will use a Type 1 Hybrid Effectiveness-Implementation approach to adapt and then test the effects of REACH TBI on key TBI caregiver outcomes.
RESULTS: This study was funded by the Department of Defense in September 2023. Participant enrollment and data collection will begin in 2024.
CONCLUSIONS: If effective, REACH TBI will be the first evidence-based intervention for caregivers of V/SMs with TBI that can be scaled to implement across the Veterans Affairs Polytrauma System of Care and fill a notable gap in clinical services.
UNASSIGNED: PRR1-10.2196/57692.

BACKGROUND: The COVID-19 pandemic highlighted the importance of telemedicine in health care. However, video telemedicine requires adequate broadband internet speeds. As video-based telemedicine grows, variations in broadband access must be accurately measured and characterized.
OBJECTIVE: This study aims to compare the Federal Communications Commission (FCC) and Microsoft US broadband use data sources to measure county-level broadband access among veterans receiving mental health care from the Veterans Health Administration (VHA).
METHODS: Retrospective observational cohort study using administrative data to identify mental health visits from January 1, 2019, to December 31, 2020, among 1161 VHA mental health clinics. The exposure is county-level broadband percentages calculated as the percentage of the county population with access to adequate broadband speeds (ie, download >25 megabits per second) as measured by the FCC and Microsoft. All veterans receiving VHA mental health services during the study period were included and categorized based on their use of video mental health visits. Broadband access was compared between and within data sources, stratified by video versus no video telemedicine use.
RESULTS: Over the 2-year study period, 1,474,024 veterans with VHA mental health visits were identified. Average broadband percentages varied by source (FCC mean 91.3%, SD 12.5% vs Microsoft mean 48.2%, SD 18.1%; P<.001). Within each data source, broadband percentages generally increased from 2019 to 2020. Adjusted regression analyses estimated the change after pandemic onset versus before the pandemic in quarterly county-based mental health visit counts at prespecified broadband percentages. Using FCC model estimates, given all other covariates are constant and assuming an FCC percentage set at 70%, the incidence rate ratio (IRR) of county-level quarterly mental video visits during the COVID-19 pandemic was 6.81 times (95% CI 6.49-7.13) the rate before the pandemic. In comparison, the model using Microsoft data exhibited a stronger association (IRR 7.28; 95% CI 6.78-7.81). This relationship held across all broadband access levels assessed.
CONCLUSIONS: This study found FCC broadband data estimated higher and less variable county-level broadband percentages compared to those estimated using Microsoft data. Regardless of the data source, veterans without mental health video visits lived in counties with lower broadband access, highlighting the need for accurate broadband speeds to prioritize infrastructure and intervention development based on the greatest community-level impacts. Future work should link broadband access to differences in clinical outcomes.