VA Rocky Mountain Network

Abstract Sensory loss is common among aging adults and has been linked to poor health outcomes, including depression, frailty, cognitive decline, falls, and poor quality of life. Vision and hearing loss are more prevalent among adults aging with HIV (AAWH) and are associated with decreased healthcare engagement. This qualitative study used a community-based participatory research approach to explore sensory health experiences, needs, and program preferences of AAWH receiving services at Colorado Health Network, a statewide AIDS Service Organization in Denver. Following purposive sampling, we conducted and audio-recorded ten individual interviews and two focus groups with 23 participants (ages 51-73), who shared their lived experiences with sensory loss and perspectives on sensory care. Audio recordings were transcribed, and data were analyzed through deductive and inductive thematic analysis and team-based triangulation. Six themes were identified: interplay of HIV and aging in sensory decline perceptions; sensory aid stigma and self-perceptions of accelerated aging; navigating affordability of sensory aids; creative behavioral, environmental, and technological adaptations to sensory loss; long-term survivorship as a driver of self-management of care and self-advocacy; integrating ideal sensory care for AAWH. Using the Social Ecological Model, we identified facilitators and barriers to sensory care at the individual, interpersonal/provider, organizational/community, and system levels. Facilitators included motivation to maintain independence, peer modeling, community-based benefits, and care navigation. Barriers included discomfort with assistive devices, stigma, provider bias, limited awareness of HIV-specific health needs, and gaps in insurance coverage. Findings offer guidance for designing community-based sensory health programs tailored to the lived experience of AAWH.

ABSTRACT Objectives The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans. Methods Pilot randomized controlled trial consists of 2,009 veterans aged ≥ 65 years who received BZRA prescriptions from a Veterans Health Administration pharmacy (Colorado or Montana) during the prior 18 months. Active: Arm 1 was a mailed brochure about BZRA risks that also included information about a free, online cognitive behavioral therapy for the insomnia (CBTI) program. Arm 2 was a mailed brochure (same as arm 1) and telephone reinforcement call. Control: Arm 3 was a mailed brochure without insomnia treatment information. Active BZRA prescriptions at follow-up (6 and 12 months) were measured. Results In logistic regression analyses, the odds of BZRA prescription at 6- and 12-month follow-ups were not significantly different for arm 1 or 2 (active) versus arm 3 (control), including models adjusted for demographics and prescription characteristics (p-values >0.36). Conclusions Although we observed no differences in active BZRA prescriptions, this pilot study provides guidance for conducting a future study, indicating a need for a more potent intervention. A full-scale trial testing an optimized program would provide conclusive results. Clinical Implications Mailing information about BZRA risks and CBTI did not affect BZRA prescriptions.

To provide a summary of the implementation of a virtual academic detailing pilot program at the US Department of Veterans Affairs (VA). In September 2018, VA Pharmacy Benefits Management implemented a virtual academic detailing ("e-Detailing") pilot program across 3 regional networks. Academic detailing involves multifaceted collaborative outreach delivered by trained healthcare clinicians to other clinicians using targeted educational interventions that improve clinical decision-making. Across VA, academic detailing programs are primarily staffed by specially trained clinical pharmacist specialists. Implementation began with an in-person meeting to train academic detailers on using the virtual academic detailing platform (VA Video Connect) and virtual soft skills, which was followed by regular facilitation meetings to address issues and share experiences. During e-Detailing program implementation, coronavirus disease 2019 (COVID-19) emerged, prompting the US Department of Health and Human Services to declare a public health emergency. VA followed with restrictions on nonessential travel for all employees, thus hampering in-person academic detailing activities. Fortunately, e-Detailing provided an alternative channel for academic detailers across VA to continue delivering critical outreach to providers during the pandemic. Qualitative assessment of academic detailers' and providers' perceptions on e-Detailing highlighted the need for local leadership support for e-Detailing and telehealth, the efficiency of virtual compared to in-person visits, and potential time savings resulting from avoidance of long commutes. The timing of e-Detailing implementation during the COVID-19 pandemic illustrates the need and potential for a virtual platform to deliver timely provider outreach.

Bipolar disorder (BP) suicide death rates are 10–30 times greater than the general population, likely arising from environmental and genetic risk factors. Though suicidal behavior in BP has been investigated, studies have not addressed combined clinical and genetic factors specific to suicide death. To address this gap, a large, harmonized BP cohort was assessed to identify clinical risk factors for suicide death and attempt which then directed testing of underlying polygenic risks. 5901 individuals of European ancestry were assessed: 353 individuals with BP and 2498 without BP who died from suicide (BPS and NBPS, respectively) from a population-derived sample along with a volunteer-derived sample of 799 individuals with BP and a history of suicide attempt (BPSA), 824 individuals with BP and no prior attempts (BPNSA), and 1427 individuals without several common psychiatric illnesses per self-report (C). Clinical and subsequent directed genetic analyses utilized multivariable logistic models accounting for critical covariates and multiple testing. There was overrepresentation of diagnosis of PTSD (OR = 4.9, 95%CI: 3.1–7.6) in BPS versus BPSA, driven by female subjects. PRS assessments showed elevations in BPS including PTSD (OR = 1.3, 95%CI:1.1–1.5, versus C), female-derived ADHD (OR = 1.2, 95%CI:1.1–1.4, versus C), and male insomnia (OR = 1.4, 95%CI: 1.1–1.7, versus BPSA). The results provide support from genetic and clinical standpoints for dysregulated traumatic response particularly increasing risk of suicide death among individuals with BP of Northern European ancestry. Such findings may direct more aggressive treatment and prevention of trauma sequelae within at-risk bipolar individuals.

Abstract Background Telemental Health (TMH) is an effective way to increase access to mental health services. For this reason, many health care systems strive to make TMH a part of routine mental health services. TMH use has increased substantially in recent years; however, health care systems have found it challenging to implement TMH ubiquitously. Minimal literature addresses system wide TMH implementation efforts. Because previous local training efforts failed in leading to meaningful uptake in TMH use, a quality improvement project guided by implementation science methodology was used to design and implement an innovative TMH training program across a large service line. Methods PARiHS criteria (i.e., Evidence, Context, Facilitation) was used as a framework to design, communicate, and implement a TMH training program aimed at providing task-specific training and culture change. The Evidence included incorporating established telehealth literature on TMH acceptance and efficacy. The Context included leadership support to prioritize training sites. RE-AIM guided the evaluation outcome measures used. The Facilitation was guided by Implementation/Facilitation techniques. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated in this training over the course of two years. Results Overall, providers reported satisfaction with the training program, and found that it increased their TMH knowledge and competence. The number of providers using TMH and patients who received it nearly doubled in the two years after the launch of the TMH training compared to the two years preceding. Conclusions Implementation science methodology was important in creating an organizational framework to design, evaluate, and facilitate implementation of an innovative TMH training program. The program was well-received by staff and increased the number of providers and patients using TMH. Since this project was completed, the COVID-19 pandemic has significantly increased the demand for telehealth services. This training model offers specific strategies based upon implementation science that could be disseminated to and adopted by mental health programs looking to implement system wide TMH use.

Abstract Background: Telemental Health (TMH) is an effective way to increase access to mental health services. For this reason, many health care systems strive to make TMH a part of routine mental health services. TMH use has increased substantially in recent years; however, health care systems have found it challenging to implement TMH ubiquitously. Minimal literature addresses system wide TMH implementation efforts. To broadly expand TMH throughout a VA medical center’s mental health service, a quality improvement project was conducted to develop and implement a comprehensive, novel TMH training program for staff. Methods: This quality improvement project was informed by implementation science methodologies. PARiHS criteria and Evidence-Based QI Implementation/Facilitation guided the development and implementation of this TMH training program, which included: (a) two online TMH courses, (b) a one-day didactic training including hands-on practice and skills evaluation, and (c) weekly calls where staff could receive TMH consultation. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated in this training over the course of two years. RE-AIM criteria were used to evaluate the effectiveness of this training program. Results: Overall, providers reported satisfaction with this TMH training program, and found that it increased their TMH knowledge and competence. The number of providers using TMH and patients who received it nearly doubled in the two years after the launch of the TMH training compared to the two years preceding. Conclusions: This novel TMH training program was well-received by staff and increased the number of providers and patients using TMH. Since this project was completed, the COVID-19 pandemic has significantly increased the demand for telehealth services. This training model offers specific strategies based upon implementation science that could be disseminated to and adopted by mental health programs looking to implement system wide TMH use.

Increasing evidence incriminates low-grade inflammation in cardiovascular, metabolic diseases, and neuropsychiatric clinical conditions, all important causes of morbidity and mortality. One of the upstream and modifiable precipitants and perpetrators of inflammation is chronic periodontitis, a polymicrobial infection with Porphyromonas gingivalis (P. gingivalis) playing a central role in the disease pathogenesis. We review the association between P. gingivalis and cardiovascular, metabolic, and neuropsychiatric illness, and the molecular mechanisms potentially implicated in immune upregulation as well as downregulation induced by the pathogen. In addition to inflammation, translocation of the pathogens to the coronary and peripheral arteries, including brain vasculature, and gut and liver vasculature has important pathophysiological consequences. Distant effects via translocation rely on virulence factors of P. gingivalis such as gingipains, on its synergistic interactions with other pathogens, and on its capability to manipulate the immune system via several mechanisms, including its capacity to induce production of immune-downregulating micro-RNAs. Possible targets for intervention and drug development to manage distal consequences of infection with P. gingivalis are also reviewed.

Abstract Introduction Growing evidence connects periodontal disease, a major and modifiable cause of local and systemic inflammation, with metabolic and cardiovascular morbidity and mortality, as well as mental illness. Sleep has been previously predictively associated with metabolic and psychiatric morbidity and mortality, and has recently been linked with periodontal disease. We are now evaluating associations between self-reported insomnia measures and surrogate indicators of periodontal disease in a population with a very low prevalence of smoking — a major confounder in previous studies. Methods Dental and sleep questionnaires (Pittsburgh Sleep Quality Index) were obtained from 3881 Old Order Amish from Lancaster county. Difficulty falling or staying asleep, sleep quality, problems during the day due to poor sleep, and sleepiness during daytime were related to self-reported loose teeth, partial dentures, full dentures and any dentures using linear models with adjustment for age and sex. Results Significant associations emerged between problems falling asleep and loose teeth (p<0.05), problems staying asleep and any dentures (p<0.05), sleep quality with loose teeth and partial, as well as complete dentures (p<0.05 for both). Problems during daytime due to poor sleep were associated with loose teeth (p<0.05), any dentures (p<0.003) and full dentures (p<0.0001 — the only associations resisting Bonferroni correction). Sleepiness during daytime, which is the most important marker associated with sleep apnea was not associated with any dental health measures. Conclusion Limitations include not accounting for family aggregation, limited generalizability, not fully differentiating between respiratory versus non-respiratory sleep impairment, and periodontal versus traumatic dental pathology. Yet, the results of our study, which minimizes the strong potential confounding by smoking, confirm associations between sleep-related problems and periodontal disease, and justify future longitudinal and interventional research to dissect causality and identify multi-target treatment modalities. Support This work was supported by the Mid-Atlantic Nutrition Obesity Research Center Preliminary Developmental NORC grant (Postolache, PI), a sub-award of the parent grant P30 DK072488 (Mitchell, PI), and intramural funds from the University of Maryland, Baltimore.

Introduction: Elective percutaneous coronary intervention (PCI) for stable angina is intended to reduce symptoms and enhance quality of life. However, measures of patient-reported health status are not yet routinely collected or used. Methods: We developed a telephonic interactive voice response (IVR) system to capture patient-reported health status measures before and after PCI in the Veterans Affairs (VA) Health Care System. The IVR system calls patients to collect Seattle Angina Questionnaire 7 and Rose Dyspnea questionnaire data 1 month prior to PCI and 1 and 6 months after PCI. Reports are provided to primary care and cardiology providers for patients who experience a significant change in health status. We performed a multi-method, interim analysis of sequential roll-out of the IVR system at 6 VA centers, including quantitative process data; semi-structured interviews with 13 patients; and chart review of all patients who experienced a decrement in health status. Results: Of 2,113 patients undergoing elective PCI from November 28, 2015, until September 31, 2019, health status data were collected from 692 (32.7%) prior to PCI, 457 (66.0%) 1 month after PCI, and 59 (8.5%) 6 months after PCI ( Figure 1 ). A total of 83 (18.0%) decrements in health status occurred. In response, 10 (12.0%) clinical actions were recorded in the medical record: 4 (4.8%) patients were called by providers, 2 (2.4%) had their medication regimen reviewed, 3 (3.6%) had their case reviewed by their primary care provider and/or an interventional cardiologist, and an outpatient clinic visit was scheduled earlier than planned for 1 (1.2%) patient. Many patients did not remember receiving a telephone call; others were “fine” with receiving a call and filling out a survey. Some expressed difficulty with completing the survey owing to a lack of technical literacy or difficulty with hearing. Some patients were reassured by a telephone call, saying “That’s good, because it lets me know that I haven’t slipped through the cracks. It builds confidence that they know how I’m feeling before a procedure.” Conclusions: It is feasible to capture patient-reported measures of health status in the real world and integrate their use into routine clinical care. Opportunities to improve the collection and use of patient-reported health status measures persist.