Dallas VA Medical Center

The Veterans Health Administration is promoting patient-reported outcome measure (PROM) collection for measurement-based mental health care. Understanding veteran preferences about how and when to complete PROMs is critical to support their implementation. We examined veteran preferences for timing and use of different technology platforms to complete mental health-related PROMs. We invited a national sample of 1373 veterans to complete a survey; 858 (62.5%) responded. Surveys asked about veteran preferences for how and when to complete mental health-related PROMs. We characterized responses using descriptive statistics and estimated multiple logistic regression models to examine associations between veteran demographic and health characteristics and preferences for completing PROMs. Most veterans preferred completing PROMs between appointments (607/801, 75.8%) using features of a patient portal (410/801, 51.2%), during appointments (589/801, 73.5%) verbally (413/801, 51.6%), and while at the medical center (480/801, 59.9%) on paper (189/801, 23.6%) or a tablet computer (180/801, 22.5%). Hispanic (vs non-Hispanic) veterans had 3.32 (95% CI 1.04-10.58) times higher odds of preferring to complete PROMs at the medical center, and veterans with lower (vs higher) socioeconomic status had lower odds (odds ratio 0.61, 95% CI 0.40-0.93) of preferring to complete PROMs in between appointments but 1.97 (95% CI 1.23-3.16) times higher odds of preferring to complete PROMs during appointments. As the Veterans Health Administration and other health care systems seek to expand the integration of PROM data into health care services, adaptive and flexible approaches to PROM administration that align with patient preferences, including those that leverage technology platforms in the remote collection of these data, may bolster implementation. Our results indicate that such implementation efforts should consider patient ethnicity and socioeconomic status. Our findings further suggest that these efforts could benefit from incorporating PROM administration into online patient portals, developing mobile health apps that support PROM completion through patients' personal devices in between clinical encounters, and engaging care team members in PROM administration during appointments.

ABSTRACTObjectiveEmbedded research partnerships can advance the implementation of evidence‐based policies and practices, including those aligned with person‐centered care. Care delivery model transformations, such as the VA's person‐centered Whole Health System (WHS), can benefit from an ongoing cycle of program implementation and their evaluation to inform future evolution. This paper describes how embedded researchers partnered with policy makers leading VA's WHS transformation to support its development, implementation, and scaling to illustrate lessons learned for embedded research.Data Sources and Study SettingFifty‐eight embedded research projects were conducted from FY2013 to FY2024.Study DesignWe recorded each project's scope, methodology, results, products, and impact. Through a group reflection process, we identified common cross‐project lessons that fostered this successful embedded research partnership. Finally, we mapped projects to phases of Kilbourne's Knowledge to Action Framework (Pre‐Implementation, Implementation, and Sustainment) to demonstrate how embedded researchers defined evaluation questions, evaluated WHS transformation, and assessed outcomes to inform the implementation and sustainment of VA's WHS transformation.Data Collection/Extraction MethodsProjects used multiple qualitative, survey, and large database methods.Principal FindingsAcross 58 projects, 380 discrete products were used by our operational partner to refine the WHS model, improve implementation support, scale effective practices, inform new policy, and sustain transformation. Three practices cut across these projects to contribute to our successful embedded research partnership: agility, collaboration, and continuous learning and improvement. Additionally, the purpose, questions, and methods of embedded research projects varied as operational partner activities moved across pre‐implementation, implementation, and sustainment phases, iteratively impacting WHS transformation.ConclusionsEmbedded research can transform a healthcare system through the timely translation of data into practice, enabling evidence‐based policy and practice decisions. Our embedded research‐operations partnership, characterized by trust, respect, and strong communication, ensured that evaluations generated an evidence base to inform both implementation and impact.

Chronic pain is a debilitating condition that disproportionately impacts US veterans who manage numerous negative pain-related outcomes. There is an urgent need for accessible, engaging, and innovative treatments that can help veterans with chronic pain better self-manage their pain at home and improve their daily functioning. Technology-delivered acceptance- and mindfulness-based interventions for pain have shown strong efficacy, particularly when they are engaging and tailored to specific client needs. However, more research is needed to assess the impact of such interventions, particularly in terms of pain-related functioning and quality of life. The primary aim of this study is to test the efficacy of Veteran Acceptance and Commitment Therapy for Chronic Pain (VACT-CP), an online self-management pain program, compared to an active online control (Online Pain School) for improving pain-related functioning in a 3-site randomized controlled trial. The secondary aim is to explore psychological flexibility as a potential mediator between pain severity and pain-related functioning. This study will use a mixed methods approach to examine the efficacy of VACT-CP in a 2-arm, multisite, randomized controlled superiority trial including 200 participants with chronic musculoskeletal pain compared to Online Pain School. Participants will be assigned to 1 of these 2 online interventions. Both interventions will include 7 modules delivered over 7 weeks, with each module lasting approximately 15 minutes. Mixed effects models will be used to analyze the primary hypothesis that participants in the VACT-CP group will have greater improvement in pain-related functioning (Brief Pain Inventory-Interference subscale) than those in the active control group (Online Pain School). The main acceptance and commitment therapy process mediator (ie, Multidimensional Psychological Flexibility Inventory), pain-related functioning outcomes (Brief Pain Inventory-Interference subscale), and quality of life (Veterans RAND 36-Item Health Survey) will be measured at baseline, end of treatment, and 3 and 6 months after treatment. In addition, qualitative exit interviews will be conducted with a random set of 30 VACT-CP users (n=10, 33% per site) to obtain intervention usability, feasibility, and acceptability information. The recruitment for this study began in January 2025. It is expected to continue through January 2027. Data collection is expected to be completed by June 2027, and primary data analyses are expected to be completed by early 2028. Online interventions such as VACT-CP and Online Pain School have the potential to expand access to behavioral interventions that improve quality of life and provide nonpharmacological pain treatment options for veterans experiencing chronic pain. However, research on their impact and underlying mechanisms of change is required to support this area of potential at-home programming. ClinicalTrials.gov NCT06058624; https://clinicaltrials.gov/study/NCT06058624. PRR1-10.2196/70601.

Context Veterans Health Administration (VHA) offers Annual Evaluations (AEs) to Veterans with spinal cord injuries and disorders (SCI/D) for preventive services, managing common complications, psychosocial services, and addressing equipment needs. Objective Obtain Veteran perceptions of AE services and examine their association with Veteran characteristics and receipt of AEs. Methods Surveys were sent to n = 8,421 Veterans in the VHA SCI/D Registry electronically (n = 8,121) or through US mail (n = 300), with a 23.64% response rate. After excluding participants with missing data, n = 1,687 Veterans were included in descriptive and logistic regression analyses. Results Respondents were aged 60.7 years (SD=11.60) on average; most were male (91.2%), white (75.9%), and non-Hispanic (90.5%). 72.4% indicated receiving their most recent SCI/D AE about one year ago, 24.8% more than one year ago, and 3.4% had never had an AE. The most frequently reported reasons for not receiving an AE were COVID-19 related concerns (46.1%), and that AE was not offered (23.4%). Most (73.7%) indicated the AE was “Very Important” for their health and well-being. Veterans living more than 120 min from their VA had lower odds (0.51, 95% CI 0.32–0.80) of reporting recent AEs compared to Veterans who lived within 30 min. Conclusions Veterans expressed high levels of satisfaction with the AE and found many aspects to be valuable. Additional strategies are needed to address travel barriers and COVID-19 related access challenges to bolster AE receipt. Future research and efforts to leverage technology for reminders may improve AE uptake.

Abstract Introduction REM sleep behavior disorder (RBD) is characterized by dream enactment behaviors, which can be dangerous in occupational settings. Obstructive sleep apnea (OSA) has been associated with parasomnia presentations and can exacerbate sleep fragmentation and REM dysregulation. This case explores the interplay of RBD and OSA in a 50-year-old truck driver, emphasizing the life-altering outcomes of OSA treatment. Report of case A 54-year-old obese male (BMI: 39 kg/m²) with restless leg syndrome and OSA with a career as a long-distance truck driver presented with frequent episodes of acting out his dreams during sleep. His typical sleep routine involved bunking in the back of his truck at highway rest stops. Twice he woke up in his truck disoriented. He also found himself waking up eating, but he had no recollection of how he got the food. Polysomnography confirmed severe OSA with an apnea hypopnea index (AHI) of 84.9 events/hour. Symptoms met diagnostic criteria for RBD based on clinical history and PSG findings. Despite reluctance to start positive airway pressure (PAP) therapy, counseling directed towards the possibility of improving RBD-like behavior helped him gain the commitment for treatment. He was initiated on Auto-Bilevel PAP therapy at Max IPAP 20 Min EPAP 4 pressure settings resolved the patient’s apneas. At a 3-month follow-up, the patient reported complete resolution of dream enactment behaviors with excellent BiPAP compliance. Conclusion REM Sleep Behavior Disorder (RBD) involves the loss of normal muscle atonia during REM sleep, resulting in behaviors ranging from yelling and kicking to highly complex actions. While some cases are idiopathic, various conditions can disrupt REM sleep regulation and contribute to its development. This case highlights the need for comprehensive sleep evaluations in parasomnia presentations, especially in high-risk occupations, to identify and address underlying conditions like OSA and potentially reduce the need for adjunctive pharmacologic therapies. Despite his severity of RBD, addressing underlying OSA as a primary therapy is a worthwhile approach. In this case, PAP therapy alone led to complete resolution of the patient’s symptoms, highlighting its significance as a first-line treatment in certain clinical scenarios. Support (if any)

Our previous work demonstrated that the DNA-sensing receptor cyclic GMP-AMP synthase (cGAS) negatively affects post-infarct repair by promoting pro-inflammatory macrophages. However, whether cGAS and its downstream partner STING (Stimulator of Interferon Genes) regulate neutrophil production and function in the context of acute myocardial ischemia remains unclear. This study investigated the role of the cGAS-STING pathway in neutropoiesis (neutrophil production and differentiation) and examined whether ischemia primes neutrophils in the bone marrow via this pathway, enhancing their functionality and contributing to cardiac inflammatory injury. Using myocardial infarction (MI) models in wild-type (WT), Cgas-/-, and Sting-/- mice, we analyzed neutrophils from the bone marrow, peripheral blood, and infarcted tissue. Additionally, we generated neutrophil-specific conditional knockouts of Cgas and performed adoptive transfer experiments with Cgas-deficient neutrophils. RNA sequencing revealed that ischemia increased neutrophil production in the bone marrow and activated pathways involved in cytokine signaling, phagocytosis, chemotaxis, and degranulation. Inhibiting the cGAS-STING pathway reduced neutrophil production by decreasing lineage committed neutrophil precursors including early neutrophil precursors (eNP) and preNeu and downregulated ischemia-induced pathways. Neutrophil conditional Cgas deletion or adoptive transfer of Cgas-deficient neutrophils improved survival but did not significantly impact ischemia-induced remodeling. In conclusion, we demonstrate for the first time that ischemia enhanced neutrophil functionality before recruitment to infarcted tissue, and the cGAS-STING pathway played an important role in neutrophil production and priming. Furthermore, our findings demonstrate a neutrophil-specific role of cGAS in promoting cardiac rupture and mortality in MI. This study provides a more comprehensive understanding of the cGAS-STING pathway in acute ischemia and may support the translation of cGAS-STING modulators, an emerging therapeutic field.

Background:Contemporary research in peripheral artery disease (PAD) remains limited due to lack of a national registry and low accuracy of diagnosis codes to identify PAD patients in electronic health records.Methods & Results:Leveraging a novel natural language processing (NLP) system that identifies PAD with high accuracy using ankle brachial index (ABI) and toe-brachial index (TBI) values, we created a registry of 103,748 patients with new onset PAD patients in the Veterans Health Administration (VHA). Study endpoints include mortality, cardiovascular (hospitalization for acute myocardial infarction or stroke) and limb events (hospitalization for critical limb ischemia or major amputation) and were identified using VA and non-VA encounters. The mean age was 70.6 years; 97.3% were males, and 18.5% self-identified as Black race. The mean ABI value was 0.78 (SD: 0.26) and the mean TBI value was 0.51 (SD: 0.19). Nearly one-third (32.4%) patients were currently smoking and 35.4% formerly smoked. Prevalence of hypertension (86.6%), heart failure (22.7%), diabetes (54.8%), renal failure (23.6%), and chronic obstructive pulmonary disease (35.4%) was high. At 1-year, 9.4% of patients had died. The 1-year incidence of cardiovascular events was 5.6 per 100 patient-years and limb events was 4.5 per 100 patient-years.Conclusions:We have successfully launched a registry of >100,000 patients with a new diagnosis of PAD in the VHA, the largest integrated health system in the U.S. The ncidence of death and clinical events in our cohort is high. Ongoing studies will yield important insights regarding improving care and outcomes in this high-risk group.