A Learning Health System Approach to Long COVID Care.

Background: Global initiatives to mitigate COVID-19 transmission have shifted health system priorities to management of patients with prolonged long COVID symptoms. To better meet the needs of patients, clinicians, and systems, a learning health system approach can use rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care.

Observations: Employees in the Veterans Health Administration formed a multidisciplinary workgroup.

Unexpected Findings During Double-blind Discontinuation of Acetylcholinesterase Inhibitor Medications.

Purpose: The long-term effects of acetylcholinesterase inhibitors (AChEIs) used in the treatment of patients with various types of dementia remain unclear, largely due to challenges in the study of their discontinuation. We present several unexpected results from a discontinuation trial that might merit further investigation.

Methods: This double-blind, placebo-controlled study of the discontinuation of AChEI medications was conducted in 62 US veterans.

Comorbid Anxiety and Depression, Though Underdiagnosed, Are Not Associated with High Rates of Low-Value Care in Patients with Chronic Obstructive Pulmonary Disease.

Patients with chronic obstructive pulmonary disease (COPD) and anxiety or depression experience more symptoms and exacerbations than patients without these comorbidities. Failure to provide beneficial COPD therapies to appropriate patients (underuse) and provision of potentially harmful therapies to patients without an appropriate indication (overuse) could contribute to respiratory symptoms and exacerbations. Anxiety and depression are known to affect the provision of health services for other comorbid conditions; therefore, underuse or overuse of therapies may explain the increased risk of severe symptoms among these patients.

Waddell (Nonorganic) Signs and Their Association With Interventional Treatment Outcomes for Low Back Pain.

Background: The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions.

Methods: We prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP.

Associations Between Activities of Daily Living Independence and Mental Health Status Among Medicare Managed Care Patients.

Background/objectives: Although there is a strong cross-sectional association between dependence in activities of daily living (ADLs) and decreased mental health, it is largely unknown how the loss of specific ADLs, or the combination of ADLs, influences mental health outcomes. We examined the effect of ADL independence on mental health among participants in a large survey of Medicare managed care recipients.

Design/setting: Retrospective cohort study.

How to Ensure That Teaching Kitchens Are Age-Friendly.

Health systems and community organizations have increasingly offered nutrition education through teaching kitchens. With an increasing number of older adults (>65 years) accessing these programs, teaching kitchens may consider age-friendly adaptations to their standard curriculum. Based on experiences with implementing Healthy Teaching Kitchens Across Veteran Affairs Health Care System, and by applying the 5M Geriatric Care Framework (Mind, Multicomplexity, Medications, Mobility, What Matters Most), several steps are proposed for teaching kitchens to be able to better accommodate older adults.

Healthy Teaching Kitchen Programs: Experiential Nutrition Education Across Veterans Health Administration, 2018.

Traditional clinical interventions yield few positive effects on diet. The Healthy Teaching Kitchen (HTK) program implemented by the Veterans Health Administration at sites across the United States delivers interactive nutrition and culinary education, guided instruction, and social opportunities for patients and caregivers. We report HTK outcomes of veterans' self-reported acceptability, self-efficacy for dietary change, and dietary and cooking habits.

Mental health treatment among older adults with mental illness on parole or probation.

Background: The number of older adults on parole and probation is growing at an unprecedented rate, yet little is known about the mental health needs and treatment utilization patterns among this group. The objective of this study is to compare the prevalence of serious or moderate mental illness (SMMI), and the proportion of those with SMMI who receive mental health treatment, among community-dwelling older adults on correctional supervision (parole or probation) vs. not on correctional supervision.

Differences in Tertiary Glaucoma Care in the Veterans Affairs Health Care System.

Importance: Glaucoma is a common cause of visual impairment in the Veterans Affairs (VA) health care system, but to our knowledge, no data exist concerning tertiary glaucoma care (ie, laser and filtering surgery).

Objective: To determine whether the rate of tertiary glaucoma care differs among veterans cared for through the 4 different eye care delivery models that are present in the VA: optometry-only clinics, ophthalmology-only clinics, clinics with optometry and ophthalmology functioning as a single integrated clinic with ophthalmology as the lead, and clinics with optometry and ophthalmology functioning as separate clinics.

Design, Setting, And Participants: In this retrospective review of the Veterans Health Administration Support Service Center database, 490 926 veterans with a glaucoma-related diagnosis received care from 136 VA medical centers during fiscal year 2016.

A longitudinal study of depression among middle-aged and senior patients initiating chronic opioid therapy.

Background: Improved understanding how depressive symptoms change with sustained opioid use is needed.

Methods: We prospectively assessed patients 45 years or older initiating chronic opioid therapy (COT) at baseline and at 4 and 12 months, differentiating recent COT initiators (n=748) and continuing users (n=468). Level of opioid use before 12-month follow-up was classified as regular/higher-dose, intermittent/lower-dose, or minimal/no use.

Electronic Health Records to Evaluate and Account for Non-response Bias: A Survey of Patients Using Chronic Opioid Therapy.

Background: In observational studies concerning drug use and misuse, persons misusing drugs may be less likely to respond to surveys. However, little is known about differences in drug use and drug misuse risk factors between survey respondents and nonrespondents.

Methods: Using electronic health record (EHR) data, we compared respondents and non-respondents in a telephone survey of middle-aged and older chronic opioid therapy patients to assess predictors of interview nonresponse.

Disparate prevalence of toxigenic and nontoxigenic Clostridium difficile among distinct adult patient populations in a single institution.

Clostridium difficile (CD) disease remains a costly and important hospital-associated infection. Although nontoxigenic CD is detected by some CD testing methods, can interfere with some detection algorithms and has been suggested as a treatment for CD disease, little is known about the relative occurrence of toxigenic and nontoxigenic CD in a single institution.We used both chromogenic and selective agar media to recover CD isolates and a molecular method to detect the toxin B gene from over 2400 fresh unformed stool specimens with isolates further tested for the toxin B gene.

A Prospective Study of Predictors of Long-term Opioid Use Among Patients With Chronic Noncancer Pain.

Background: Chronic pain patients at increased risk of unfavorable pain and opioid misuse outcomes may be those most likely to use opioids long-term, but this has not been evaluated prospectively.

Objectives: To ascertain whether pain prognostic risk, problem opioid use risk, and depression predict opioid use 1 year later among patients recently initiating opioid therapy with a moderate likelihood of long-term opioid use.

Materials And Methods: Self-report and electronic health record data were collected from patients aged 45+ years who recently initiated opioid therapy (N=762), in an integrated health care system.

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging.

Importance: National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic.

Timeliness of Care Planning upon Initiation of Chronic Opioid Therapy for Chronic Pain.

Background: Chronic opioid therapy (COT) guidelines recommend developing a COT care plan at the initiation of COT.

Objective: Assess the timeliness of care planning upon initiation of COT.

Design: Observational cohort study in a setting incentivizing and tracking documentation of COT care plans in electronic health records (EHRs).

Sex, Race, and Age Differences in Observed Years of Life, Healthy Life, and Able Life among Older Adults in The Cardiovascular Health Study.

Objective: Longevity fails to account for health and functional status during aging. We sought to quantify differences in years of total life, years of healthy life, and years of able life among groups defined by age, sex, and race.

Design: Primary analysis of a cohort study.

Evaluation of Health Plan Interventions to Influence Chronic Opioid Therapy Prescribing.

Objectives: Evaluate health plan interventions targeting physician chronic opioid therapy (COT) prescribing.

Materials And Methods: In 2006, Group Health's (GH) Integrated Group Practice (IGP) initiated diverse interventions targeting COT prescriber norms and practices. In 2010, the IGP implemented a COT guideline, including a mandated online course for physicians managing COT.

Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.

A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis.

Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America.

A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis.

Treatment receipt and outcomes among lung cancer patients with depression.

Aims: Among lung cancer patients, depression has been associated with increased mortality, although the mechanisms are unknown. We evaluated the association of depression with mortality and receipt of cancer therapies among depressed veterans with lung cancer.

Materials And Methods: A retrospective, cohort study of lung cancer patients in the Veterans Affairs-Northwest Health Network from 1995 to 2010.

Do patient-perceived pros and cons of opioids predict sustained higher-dose use?

Objectives: Chronic opioid therapy (COT) is associated with various adverse outcomes, especially at higher doses, yet little is known about predictors of sustained higher-dose COT. This study aimed to ascertain, among higher-dose COT patients, the association of patient-perceived pros and cons of opioids with continued higher-dose use 1 year later.

Methods: Patients (N=1229) in 2 large health plans prescribed ≥50 mg morphine-equivalent dose (MED) per day for chronic noncancer pain completed a survey assessing opioid benefits and harms.