Tuscaloosa VA Medical Center

Abstract Background Sexual and gender minority (SGM) Veterans are more likely to require home care services than non-SGM Veterans. However, fear of discrimination deters many from seeking these supports. This landscape analysis seeks to assess team readiness and experiences with older SGM veterans within the U.S. Department of Veterans Affairs’ (VA) Home Based Primary Care (HBPC) program. Methods Using a multi-method approach, we conducted a survey of VA HBPC staff nationwide and five focus groups with staff at select sites. Results Of approximately 10,000 HBPC staff invited to participate, 321 responded. Respondents included clinicians (44%; e.g., nurses and physicians), social workers (20%), and other staff (31%; e.g., nutritionists). Most reported minimal training on SGM care, with over half (54%) receiving less than three hours in the past five years; 12% received no training at all. Despite this, 43% strongly agreed they were aware of the unique challenges faced by SGM Veterans and 46% somewhat agreed. Regarding community resources for SGM Veterans, 71% endorsed confidence in finding facilities safe from discrimination, but only 61% endorsed confidence finding an affirming one. In focus groups, staff reported limited experience with SGM veterans and raised concerns about the inclusivity of community resources. They also noted a strong desire for training in SGM care. Conclusion Our landscape assessment found that HBPC staff had concerns about the inclusivity and affirming nature of both VA and external services. Further training and resources are needed to enable the VA to deliver exemplary, affirming care for older SGM Veterans.

Background: Congenital heart anomalies (CHA) remain one of the leading causes of childhood morbidity and mortality worldwide, with significant implications for long-term health outcomes and healthcare systems. Method: Utilizing global burden of disease 2021 study standardized methodology we estimated CHA burden for all 27 European Union countries from1990-2021. Age-standardized rates of deaths, prevalence, and years lived with disability (YLDs) were analyzed, and annualized percentage changes (APC) were calculated for multiple time intervals to assess temporal and sex-specific trends. Result: From 1990 to 2000, the APC in deaths due to CHA declined significantly by -5.72%, followed by a continued but less steep decline of -3.90% from 2000 to 2021. In contrast, the prevalence showed a slight annual decrease of -0.12% during 1990–2000, which reversed to a modest annual increase of 0.19% in the period 2000–2021. YLDs demonstrated a similar trend, with an annual decline of -0.58% from 1990 to 2000 and a slight increase of 0.12% annually from 2000 to 2021. The age-standardized death rate (ASMR) declined annually by -5.10% from 1990 to 2000 and -4.00% from 2000 to 2021, while the age-standardized prevalence rate (ASPR) remained largely stable during 1990–2000 (0.006% per year) and rose slightly thereafter (0.11% per year); similarly, YLDs (ASYLDsR) showed a mild decline in the first decade (-0.17%) followed by a gradual annual increase of 0.19% from 2000 to 2021. Nationally, the highest APC in ASPR observed in Austria by 0.66%, followed by Ireland 0.23%, Portugal 0.22%, Croatia 0.19%, Malta 0.16%. From 2000 to 2010, the ASMR declined annually by -4.30% in males and -4.58% in females, with a slower decline observed from 2010 to 2021 (-3.48% in males, -3.80% in females). The prevalence rate showed a modest annual increase in males (0.28%) and a slight decline in females (-0.05%) during 2000–2010, followed by a small rise in both sexes from 2010 to 2021 (0.02% in males, 0.18% in females). YLDs remained stable in females (-0.007%) and increased marginally in males (0.23%) from 2010 to 2021. Conclusion: While the mortality due to CHA has steadily declined across 3 decades and sexes, both prevalence and disability burden have shown a gradual upward trend since 2000, particularly among males. These findings highlight a shifting burden from fatal to non-fatal outcomes, underscoring the need for long-term care strategies and quality-of-life interventions.

Heart failure (HF) is a growing global health concern, and cirrhosis is an increasingly recognized non-cardiac contributor through mechanisms like volume overload, systemic inflammation, and cirrhotic cardiomyopathy. As the global prevalence of liver disease rises, especially from nonalcoholic fatty liver disease (NAFLD), alcohol use, and viral hepatitis, understanding the burden of HF due to cirrhosis is essential. We estimated the non-fatal burden of HF attributable to cirrhosis across five etiologies—NAFLD, alcohol use, hepatitis C, hepatitis B, and other causes—in 204 countries and territories from 1990 to 2021 using data from the Global Burden of Disease Study 2021. Non-fatal burden was estimated by applying standardized severity distributions and disability weights to the prevalence of each cause to quantify impairment. Age-standardized prevalence rates (ASPRs) and annualized percentage changes (APCs) were calculated by SDI, age, and sex. Future prevalence to 2050 was projected using a log-linear regression model. Between 1990 and 2021, total prevalence counts rose substantially across all cirrhosis subtypes. NAFLD-related HF increased from 9,202 (95% UI: 6,417–12,641) to 30,092 (20,452–42,009); alcohol-related from 35,701 (27,666–45,427) to 82,258 (61,635–108,803); hepatitis C from 47,484 (37,044–60,873) to 92,079 (70,272–120,432); hepatitis B from 59,974 (47,824–74,529) to 112,111 (87,717–142,335); and other causes from 99,977 (77,246–129,309) to 133,311 (102,461–169,414). The highest ASPR increase was seen in low SDI regions (APC: 2.49%), followed by high SDI (2.24%), middle (1.73%), high-middle (1.67%), and low-middle SDI (1.60%) regions. In 2021, children aged 5–9 years exhibited the highest burden within the under-20 group (26,749 cases), while adults aged 65–69 years had the peak burden among older individuals (51,379 cases). Females showed a marginally higher annual growth in total prevalence (APC: 0.79%) and ASPR (0.04%) compared to males (0.78% and 0.01%, respectively). Projections estimate the prevalence of heart failure due to cirrhosis will increase to 788,332 cases globally by 2050. HF attributable to cirrhosis is a growing global health concern with rising prevalence across all etiologies, disproportionately impacting low-SDI regions and older adults. The projected surge by 2050 underscores an urgent need for integrated liver-cardiac care, early detection, and policy interventions targeting modifiable liver disease risk factors.

Background: Stroke is a major global health threat, with high systolic blood pressure (HSBP) as its leading modifiable risk factor. G20 nations—home to over 60% of the world’s population—face a growing burden driven by demographic shifts and uneven health policies. Despite their resources, comparative assessments of HSBP-attributable stroke trends across G20 countries remain scarce. Methods: Using the GBD 2021 analytical framework, we estimated the stroke burden attributable to HSBP in G20 countries from 1990-2021, stratified by age, sex, year, and location. Age-standardized mortality rates (ASMR), disability adjusted life years (DALYs) (ASDALR), years lived with disability (YLDs) (ASYLDsR), and counts were analyzed, and temporal trends were quantified using estimated annual percentage change (APC). Result: From 1990 to 2021, stroke deaths attributable to HSBP in G20 countries rose from 2.0 million (95% UI: 1.5–2.5) to 3.0 million (2.2–3.8), DALYs increased from 46.2 million (34.7–57.3) to 64.4 million (48.1–80.0), and YLDs doubled from 3.0 million (2.0–4.1) to 6.2 million (4.1–8.5). Age-standardized rates showed modest annual percentage declines: ASMR by 0.4%, ASDALR by 0.37%, and ASYLDR by 0.04%. Nationally, South Africa recorded the highest rise in ASMR (APC: +0.54%), followed by Indonesia (+0.33%), while most countries showed a downward trend. For ASYLDR, China reported the steepest increase (APC: +1.11%), followed by Indonesia (+0.025%), whereas the U.S. experienced a notable decline (−0.55%). By age, the highest unadjusted death rate in 2021 occurred in individuals aged ≥55 years [251 (186–315) per 100,000], compared to 8.47 (5.99–10.78) in those aged 20–54. Sex-wise, males experienced a greater burden increase than females from 1990–2021: deaths rose by 65% vs 29%, DALYs by 54% vs 25%, and YLDs by 118% vs 96%. Conclusion: In 2021, G20 countries accounted for 72.41% of global stroke deaths attributable to HSBP, while within the G20, 57.84% of all stroke deaths were attributed to HSBP. Despite overall declines in age-standardized rates, the rising absolute burden of stroke attributable to HSBP—particularly among males, older adults, and emerging G20 economies—highlights the urgent need for targeted hypertension control strategies and equitable stroke prevention efforts.

BackgroundSafety-net hospitals (SNH) provide care to a significant proportion of low-income, uninsured, and underserved populations disproportionately affected by the COVID-19 pandemic. We evaluated the impact of safety-net burden on outcomes of COVID-19 hospitalizations.MethodsWe identified patients aged ≥ 18 years hospitalized with COVID-19 from the nationwide inpatient database using the International Classification of Diseases, Tenth Edition (ICD-10-CM) code U07.1. The primary study outcomes were inpatient mortality, respiratory failure requiring mechanical ventilation, and tracheostomy use. Secondary outcomes were total hospitalization costs (THC) and length of hospital stay (LOS). Multivariable logistic regression was used to compare the primary and secondary outcomes in HBH and medium safety-net burden (MBH) with lower-burden hospitals (LBH) (reference).ResultsAn estimated 2,608,232 COVID-19 hospitalizations met the inclusion criteria, with 68.7% occurring in HBH, 22.8% in MBH, and 8.5% in LBH. On adjusted multivariable analysis, HBH was associated with increased odds of inpatient mortality (aOR 1.19, 95% CI 1.09-1.28) compared with LBH. Both HBH (aOR 1.30, 95% CI 1.21-1.40) and MBH (aOR 1.14, 95% CI 1.06-1.24) demonstrated increased odds of mechanical ventilation compared with LBH. THC was lower in HBH and MBH compared with LBH. The LOS was similar across safety net burden categories.ConclusionAfter adjusting for patient- and hospital-level factors, COVID-19 hospitalizations at HBH had inferior inpatient outcomes compared with LBH. Targeted policy reforms are needed to address the underlying causes of these disparities and increase our health systems' readiness for future crises, particularly in underserved communities.

Aims: The Veterans Health Administration (VA) is the largest healthcare entity in the United States dedicated to serving Veterans. The VA has focused on improving resident-centered care through increased communication and strengthened relationships am

Background: Access to healthcare is a significant challenge for rural veterans, especially those with chronic conditions; yet, research on their specific barriers remains limited. This study had three objectives: (1) to develop and validate the Rural Access to Care and Services Scale (RACSS) as a simple tool to assess access to physical, mental, and social care and services; (2) to examine whether minority veterans face greater barriers to care; and (3) to test whether RACSS scores are associated with psychosocial outcomes as theoretically expected. Methods: Data were collected from 500 rural veterans in the U.S. through a survey assessing demographic information, service-connected disability status, clinical conditions, and access to healthcare. First, the RACSS was developed and validated using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). Second, to assess the reliability of the RACSS, internal consistency was evaluated using Cronbach's alpha. Finally, independent sample t-tests were conducted to explore the relationships between access to healthcare and services and participants' minority status. Results: The scale demonstrated a one-factor structure with excellent model fit indices and high internal consistency (α = 0.89). Veterans from minoritized racial and ethnic groups reported significantly higher difficulties in accessing healthcare and services. Conclusions: The RACCS provides a reliable tool to measure access to healthcare and services among rural veterans. The findings highlight the critical need for targeted interventions to improve access to healthcare and services, especially for veterans from minoritized racial and ethnic groups. Enhancing healthcare and service delivery in rural areas is essential to reducing disparities and improving health outcomes for this underserved population.

When discussing neurotransmitters whose signaling plays an important role in psychiatric illnesses, serotonin and dopamine may be the first that come to mind. Although serotonin and dopamine have significant roles, the impact of norepinephrine signaling is often overlooked. A growing body of evidence suggests that hyperactivity of norepinephrine signaling is an underlying issue in psychiatric disorders; conversely, there is evidence to suggest that deficits in the noradrenergic system are just as significant. Hence, alterations in noradrenergic activity are better characterized as dysregulation rather than a reductive, outdated formulation of "too much" or "too little" activity. Therefore, symptoms such as agitation, irritability, hyperarousal, and insomnia could be treated by targeting the underlying pathophysiology related to noradrenergic dysregulation with targeted treatments. In a recent consensus panel meeting, 5 experts reviewed the available evidence of altered noradrenergic activity and its potential role in some of the most common psychiatric disorders. This Academic Highlights article summarizes their discussion and presents the panel's conclusions.

To explore the associations between depression, anxiety, decisional conflict and advance care planning engagement and the potential mediating role of decisional conflict in the associations between depression, anxiety and advance care planning among community-dwelling older adults. A cross-sectional study was conducted with 262 community-dwelling older Australians across metropolitan, regional and rural communities between August and October 2022. Validated self-reported questions were used to collect data on anxiety, depression (Hospital Anxiety and Depression Scale), decisional conflict (Decisional Conflict Scale), advance care planning engagement (Advance Care Planning Engagement Survey) and covariates (demographic characteristics, health literacy [Health Literacy Screening Questions]), overall health status (Short form 36). Data analysis included descriptive statistics, bivariate association analysis, general linear modelling and path analysis. Anxiety and decisional conflict were directly associated with advance care planning engagement even after controlling for potential effects of demographic characteristics, health literacy and overall health status. The model, including age, gender, country of birth, language spoken at home, education, overall health status, anxiety, depression, decisional conflict and interaction between anxiety and decisional conflict, explained 24.3% of the variance in their advance care planning engagement. Decisional conflict mediated the association between anxiety and advance care planning engagement. Increased anxiety and decisional conflict were associated with reduced advance care planning engagement directly, even among community-dwelling older adults with higher levels of education and health literacy. Increased anxiety was associated with reduced advance care planning engagement indirectly via increased decisional conflict. Healthcare professionals should assess community-dwelling older adults' anxiety and implement interventions to manage their anxiety and decisional conflict, as these may facilitate their engagement in advance care planning. Understanding factors associated with advance care planning engagement among community-dwelling older adults may inform strategies facilitating their future engagement in advance care planning. Findings from this study may be used as evidence for future implementation to facilitate the engagement of community-dwelling older adults in advance care planning. The STROBE statement checklist was used as a guide to writing the manuscript. The study was advertised publicly through social media (e.g. Twitter and Facebook) and newsletters (e.g. Advance Care Planning Australia, Centre for Volunteering, Palliative Care Australia and a large home care service provider with approximately 7000 older clients receiving support or services) to recruit participants. People aged 65 years and older living independently in the Australian community who could communicate in English were invited to participate and answer the questionnaire.

BACKGROUND: Employers are increasingly seeking a competitive advantage through targeted hiring of people with disabilities. We conducted several case studies to learn more about companies that led in creating their own disability diversity initiatives. OBJECTIVE: In this article, we share insights emerging from case studies conducted across seven companies. We illustrate the motives, processes, and outcomes of these initiatives. METHODS: This study is built on the previously published case studies conducted across seven companies. We applied elements of consensual qualitative research (CQR) for the data collection and analyses before performing an in-depth qualitative content analysis using the data coded for each company, looking for commonalities and differences. RESULTS: Although practices differed, all companies experienced noted benefits. Committed leadership and complementary company values facilitated successful outcomes for initiatives. The strength or salience of disability-inclusive actions and practices appeared to moderate outcomes related to company performance, employee perceptions of the company, and cohesiveness. CONCLUSION: Company disability initiatives can yield positive impacts on company performance and culture. The practices we identified and their positive outcomes serve as beacons to other organizations that recognize disability as a valued part of company diversity.