VA Capitol Health Care Network

Abstract Background Tobacco smoking rates have declined for the general population, but remain high for individuals with mental illness. Increasing access to tobacco treatment interventions in mental health settings is essential to address this health inequity. This systematic review aimed to determine how implementation strategies change mental health provider delivery of tobacco interventions. Methods We searched PubMed, PsycInfo, CINAHL, Ovid MedLine, Embase, and grey literature from inception through December 31, 2024. Implementation strategies, behavior change mechanisms, and outcomes were categorized using the Expert Recommendations for Implementing Change (ERIC) taxonomy, capability-opportunity-motivation behavioral model, and Reach, Effectiveness, Adoption, Implementation, Maintenance framework, respectively. Changes in provider adoption of implementation activities or the 5As (Ask, Advise, Assess, Assist, Arrange), and changes in reach of 5As to patients, were primary outcomes and reported as a percentage change after, compared to before, the implementation strategy. Results Twenty of 786 studies met inclusion criteria. Half (55%) were at serious risk of bias due to confounding. For behavior change mechanisms, all outpatient studies addressed clinician capability, and all inpatient studies addressed clinician opportunity to provide tobacco interventions. Reach was the most common outcome evaluated, with the largest absolute increases in proportion of patients being Assisted with referrals across both outpatient (42%) and inpatient (11%) settings after implementation. ERIC domains that maximized nicotine replacement therapy (NRT) delivery differed by setting: Strategies used in the engaging consumers domain were associated with 16% NRT increases in outpatient settings and supporting clinicians and changing infrastructure increased NRT by 20% in inpatient settings. Conclusion Interactions between setting, implementation domain, and outcomes improved reach of tobacco interventions to varying degrees in mental health settings, but formal analyses are needed to confirm hypothesized moderators (inpatient vs. outpatient) and mediators (capability, opportunity, motivation) of change. Strategies that engage consumers in outpatient settings and change infrastructure in inpatient settings may be particularly useful for improving reach of tobacco medications. Future implementation trials must monitor changes in the gold-standard tobacco interventions (medication + counseling) to maximize the clinical impact of provider practice improvements. Clinical-research partnerships are also needed to explore feasible ways to evaluate smoking changes in real-world clinical settings.

BackgroundThe CDC recommends routine sexual histories (SH), yet they are rarely completed in primary care (PC) due to barriers ranging from patient discomfort to provider time constraints. We implemented a system wide nurse-led sexual health screening tool at a large VA hospital. Here we report on patient acceptability of sexual histories and sexual behaviors of Veterans at a population level.Table 1Demographics, Overall by Question 1 ResponseThis table describes demographics of those who agreed to discuss their sexual health, ie said Yes to Question 1MethodsWe deployed a short SH screening questionnaire to be conducted during PC visits. Administered mostly by nurses, the questionnaire began with a consent question. Those with an affirmative response proceeded to answer additional questions. We queried the VA’s electronic database to ascertain patient demographics including age, birth sex, sexual orientation, gender identity, race/ethnicity, Rural-Urban Commuting Area codes. We describe the population as medians and proportions.Table 2Demographics, Overall by Question 2 ResponseThis table describes demographics of those who agreed to discuss about sexual health and have more than one sexual partner, ie said Yes to Question 2ResultsOver 2-years (April 14, 2022-24) 130,986 SH screening questionnaires were offered to 95,490 unique Veterans, with 83,510 (87%) agreed at least once (Table 1). Birth sex females were more likely than males to agree to SH (91% vs. 87%). Most 65 and older agreed to the screening (85%). Supermajority of Veterans who have recorded a sexual identity as LGBQ+ agreed to SH (1688/1798, 94%). Similarly, 96% of those who have recorded self-identified gender as transgender man, transgender woman, or non-binary also agreed to SH. Racial or ethnic minority patients were more likely to agree to SH than Whites: 90% Black vs. 87% White; 91% vs. 87% non-Hispanic. Of 83,510 patients who agreed, 2754 (3%) had more than 1 sexual partner in the last 6 months, with younger age, LGBQ+ identity, Black race and Hispanic ethnicity associated with likelihood of more than 1 sexual partner (Table 2). Of these, 4% reported sexual partners of more than 1 gender, and 21% of this subset had a self-described sexual orientation as straight or heterosexual.Sexual Health QuestionsConclusionA brief SH screening questionnaire administered by nurses in PC settings is feasible and highly acceptable to patients. Patients who identify as minority racial, ethnic, sexual or gender identity groups are very willing to provide SH, in some cases at much higher rates than non-minority peers. Other healthcare systems can implement similar nurse-led screening tools to improve SH taking in PC settingsAge Breakdown for Question 1This table describes the age breakdown for those who said Yes to Question 1, indicating both young and old population agree to discuss about sex.DisclosuresAll Authors: No reported disclosures

ABSTRACT Food security among rural veteran populations is an understudied subject. This study uses qualitative data from 106 semi-structured interviews conducted with staff from programs at the United States Department of Veterans Affairs (VA) and other federal agencies, staff from non-governmental organizations (NGOs), food security researchers, and food insecure veterans to identify the barriers to and facilitators for rural veteran food security. Barriers identified included external, structural barriers that exist in rural areas; internal barriers to using food assistance, such as feeling stigmatized; and barriers related to other social determinants of health, including a lack of education, employment, or housing stability.

As the pandemic progressed, the use of extracorporeal membrane oxygenation (ECMO) for COVID-19-related acute respiratory distress syndrome increased, and patient triage and transfer to ECMO centers became important to optimize patient outcomes. Our objectives are to identify predictors of patient transfer for veno-venous extracorporeal membrane oxygenation (V-V ECMO) evaluation as well as to describe the outcomes of accepted patients. This is a single-center, retrospective analysis of V-V ECMO transfer requests for adult patients with known or suspected COVID-19 and respiratory failure from March 2020 until March 2021. Data were collected prospectively during the triage process for transfer requests as part of clinical patient care at our institution. Of 341 referred patients, 112 (33%) were accepted for transfer to our facility, whereas 229 (67%) patients were declined for transfer. The Classification and Regression Tree analysis showed that patients' high pressure during airway pressure release ventilation (APRV) and age were the variables most significantly associated with the decision to accept or decline patients for transfer. Our triage process enabled one-third of referred patients to be transferred for evaluation, with nearly 70% of those patients ultimately receiving ECMO support. High ventilator settings on APRV and young age were associated with acceptance for transfer. Accepted patients also had a higher incidence of adjunctive therapies (proning and paralysis) prior to transfer request, less cardiac or renal dysfunction, and a shorter duration of mechanical ventilation. Further research is warranted to investigate the outcomes of nontransferred patients.

Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment. To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes. A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications. Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978). The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters. Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45). Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission. ClinicalTrials.gov Identifier: NCT03170362.