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Introduction Lung cancer screening (LCS) uptake is low. Assessing patients’ cigarette pack-years and years since quitting is challenging given the lack of documentation in structured electronic health record data. Materials and Methods We used a convenience sample of patients with a chest CT scan in the Veterans Health Administration. We abstracted data on cigarette use from electronic health record notes to determine LCS eligibility based on the 2021 U.S. Preventive Services Task Force age and cigarette use eligibility criteria. We used these data as the “ground truth” of LCS eligibility to compare them with structured data regarding tobacco use and a COPD diagnosis. We calculated sensitivity and specificity as well as fast-and-frugal decision trees. Results For 50-80–year-old veterans identified as former or current tobacco users, we obtained 94% sensitivity and 47% specificity. For 50-80–year-old veterans identified as current tobacco users, we obtained 59% sensitivity and 79% specificity. Our fast-and-frugal decision tree that included a COPD diagnosis had a sensitivity of 69% and a specificity of 60%. Conclusion These results can help health care systems make their LCS outreach efforts more efficient and give administrators and researchers a simple method to estimate their number of possibly eligible patients.

Medication for opioid use disorder, including buprenorphine and methadone, is considered the gold standard treatment for opioid use disorder (OUD). As the number of patients receiving buprenorphine has grown, clinicians increasingly care for patients prescribed buprenorphine who present for surgery and require management of perioperative pain. To describe practice patterns of perioperative and post-surgical use of buprenorphine among patients prescribed buprenorphine for OUD who experience major surgery. Retrospective cohort study utilizing data from the VA Corporate Data Warehouse (CDW), a national repository of patient-level data. Data not accessible in CDW, including clinical instructions to patients to modify buprenorphine dose, were accessed via chart review. National sample of patients receiving care through the Veterans Health Administration. We report descriptive statistics on the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, as well as post-surgical outcomes. Multivariable logistic regression identified socio-demographic and clinical characteristics associated with perioperative hold. Our final sample comprised 183 patients, the majority of whom were white and male. Most patients (66%) experienced a perioperative buprenorphine dose hold: during the pre-operative, day of surgery, and post-operative periods, 40%, 62%, and 55% of patients had buprenorphine held. Buprenorphine dose hold was less likely for patients who had experienced homelessness/housing insecurity in the year prior to surgery (aOR = 0.25; 95% CI 0.10–0.61) as well as patients residing in rural areas (aOR=0.29; 0.12–0.68). Within the 12-month period following surgery, 122 patients (67%) were retained on buprenorphine, 10 patients (5.5%) had experienced an overdose, and 15 (8.2%) had died. We identified high rates of perioperative buprenorphine dose holds. As holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care.

BACKGROUND: Hospitalization of patients with opioid use disorder (OUD) is increasing, yet little is known about opioid agonist therapy (OAT: methadone and buprenorphine) administration during admission. OBJECTIVE: Describe and examine patient- and hospital-level characteristics associated with OAT receipt during hospitalization in the Veterans Health Administration (VHA). PARTICIPANTS: A total of 12,407 unique patients, ≥ 18 years old, with an OUD-related ICD-10 diagnosis within 12 months prior to or during index hospitalization in fiscal year 2017 from 109 VHA hospitals in the continental U.S. MAIN MEASURE: OAT received during hospitalization. KEY RESULTS: Few admissions received OAT (n = 1914; 15%) and when provided it was most often for withdrawal management (n = 834; 7%). Among patients not on OAT prior to admission who survived hospitalization (n = 10,969), 2.0% (n = 203) were newly initiated on OAT with linkage to care after hospital discharge. Hospitals varied in the frequency of OAT delivery (range, 0 to 43% of qualified admissions). Patients with pre-admission OAT (adjusted odds ratio [AOR] = 15.30; 95% CI [13.2, 17.7]), acute OUD diagnosis (AOR = 2.3; 95% CI [1.99, 2.66]), and male gender (AOR 1.52; 95% CI [1.16, 2.01]) had increased odds of OAT receipt. Patients who received non-OAT opioids (AOR 0.53; 95% CI [0.46, 0.61]) or surgical procedures (AOR 0.75; 95% CI [0.57, 0.99]) had decreased odds of OAT receipt. Large-sized (AOR = 2.0; 95% CI [1.39, 3.00]) and medium-sized (AOR = 1.9; 95% CI [1.33, 2.70]) hospitals were more likely to provide OAT. CONCLUSIONS: In a sample of VHA inpatient medical admissions, OAT delivery was infrequent, varied across the health system, and was associated with specific patient and hospital characteristics. Policy and educational interventions should promote hospital-based OAT delivery. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05815-0) contains supplementary material, which is available to authorized users.

To determine the effects of the COVID-19 associated restrictions on the ability of owners in Michigan (MI), USA versus Ontario (ON) and British Columbia (BC), Canada, to obtain care for their chronically painful dogs.Cross-sectional survey.A total of 90 owners met the inclusion criteria for the study.An anonymous electronic survey was distributed to owners at four veterinary integrative medicine (IM) clinics during July and August 2020. Two clinics in MI and one each in ON and BC were recruited. Owners were asked about availability of IM care preceding and during COVID-19 restrictions and their opinions of the impact of COVID-19 on their dog's health. The survey asked where owners sought care for their dogs, types of chronic conditions treated, therapeutic modalities used, and if owners had a medical background. Comparisons were made within and between groups. Thematic analysis, Fisher's exact test, chi-square analyses, McNemar's and Wilcoxon signed-rank tests for paired comparisons were performed (p0.05).During COVID-19 restrictions, access to IM care was better for dogs in ON and BC than in MI (p0.001). The negative effect of the pandemic restrictions to IM care on quality of life was perceived greater by owners in MI than those in ON and BC (p0.001). The owners' medical backgrounds had no effect on attempts to access care during this time (p = 0.76).The results suggest that a widespread disease in humans had an adverse impact on animal welfare. Providers of veterinary care should use this experience to establish protocols to ensure continuity of care for chronically painful animals in the event of a similar situation in the future.

Objective The purpose of this study is to examine the extent to which numeric rating scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health-related quality of life (HRQOL). Design We conducted a secondary analysis of data from a prospective cohort study. Subjects We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. Setting VA Portland Health Care System outpatient clinic. Methods All patients had been screened with the 0–10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every 6 months for 2 years. Accounting for nonindependence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes. Results NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B’s = 0.53–0.59) and modestly associated with pain disability scores (B’s = 0.33–0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B’s = 0.09–0.26, with the preponderance of B’s Conclusions Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.

OBJECTIVE: To assess the impact of direct acting anti-viral (DAA) therapy for hepatitis C virus (HCV) infection on changes in pain intensity and prescription opioid use among Veterans. METHODS: We conducted a retrospective cohort study of Veterans with HCV who were seen in a rheumatology clinic at least once while receiving DAA therapy between January 1, 2010 and December 31st 2016. Demographic characteristics, HCV status, HCV treatment characteristics, numeric rating scale (NRS) pain scores and opioid prescription data were extracted from the electronic medical record. Pain scores were averaged over 6 months prior to HCV treatment and 6 months after completion of treatment. Prescription opioid dose was converted to a morphine equivalent daily dose (MEDD) and averaged across the two 6-month intervals. Generalized estimating equations were used to model the change in average pain and MEDD from pre- to post-HCV treatment. Effect size was assessed using Cohen’s d. RESULTS: A total of 121 Veterans, 91% male with average age of 59 were included. Average pre-treatment pain was 4.4 (SD 2.4). The average reduction in pain scores was 0.6 points (P = 0.02, Cohen’s d = 0.22) after treatment. Among 67 patients prescribed chronic opioid therapy at baseline, average pre-treatment MEDD was 52.4 mg (SD = 62.5 mg) and post-DAA treatment average MEDD was 49.5 mg (SD = 69.3 mg), representing a decrease by 2.9 mg (P < 0.01, Cohen’s d = 0.14). Opioid dose reduction was seen in 43/67 patients and 12 patients discontinued opioids entirely. CONCLUSION: Among US Veterans, subjective pain scores had modest improvement and opioid prescriptions were mildly reduced following treatment with DAA.

We compared smoking status from Veterans Health Administration (VHA) structured data with text in electronic health record (EHR) to assess validity. We manually abstracted the smoking status of 5,610 VHA patients. Only those with a smoking status found in both EHR text data and VHA structured data were included (n=5,289). We calculated agreement and kappa statistics to compare structured data vs. manually abstracted EHR text smoking status. We found a kappa statistic of 0.70 and total agreement of 81.1% between EHR text data and structured data for Current, Former, and Never smoking categories. Comparing EHR text data and structured data between Never and Ever smokers revealed a kappa statistic of 0.62 and total agreement of 89.1%. For comparison between Current and Never/Former smokers, the kappa statistic was 0.80 and total agreement was 90.2%. We found substantial and significant agreement between smoking status in EHR text data and structured data that may aid in future research.

Key Points Question Is the implementation of an interprofessional education initiative in US Department of Veterans Affairs primary care clinics associated with changes in quality of care? Findings In this study using difference-in-differences analysis of Department of Veterans Affairs electronic health record data, patients cared for by resident clinicians who participated in a large, multisite, interprofessional education quality improvement initiative had modestly improved quality of care compared with patients cared for by resident clinicians at similar, nonparticipating Department of Veterans Affairs teaching clinics. Meaning In this study, interprofessional education in primary care was associated with improvements in quality of care., This study estimates the association of a multisite interprofessional education initiative in the US Department of Veterans Affairs primary care clinics with quality of care., Importance Studies have shown that interprofessional education (IPE) improves learner proficiencies, but few have measured the association of IPE with patient outcomes, such as clinical quality. Objective To estimate the association of a multisite IPE initiative with quality of care. Design, Setting, and Participants This study used difference-in-differences analysis of US Department of Veterans Affairs (VA) electronic health record data from July 1, 2008, to June 30, 2015. Patients cared for by resident clinicians in 5 VA academic primary care clinics that participated in the Centers of Excellence in Primary Care Education (CoEPCE), an initiative designed to promote IPE among physician, nurse practitioner, pharmacist, and psychologist trainees, were compared with patients cared for by resident clinicians in 5 regionally matched non-CoEPCE clinics using data for the 3 academic years (ie, July 1 to June 30) before and 4 academic years after the CoEPCE launch. Analysis was conducted from January 18, 2018, to January 17, 2019. Main Outcomes and Measures Among patients with diabetes, outcomes included annual hemoglobin A1c, poor hemoglobin A1c control (ie

This assessment of common primary care measures from 10 Veterans Affairs clinics from 2014 compares outcomes in patients of resident physicians with patients of attending physicians.

With the rapid changes in the legalization of cannabis in the U.S., there is an urgent need to understand clinical outcomes and processes of care among patients who use cannabis, particularly among patients with chronic pain who are high utilizers of cannabis. Electronic health records (EHRs) are a common and convenient mechanism for examining processes of care; however, there is not an indication for cannabis use that does not meet criteria for a diagnostic disorder. We used urine drug test (UDT) results identified through EHRs to identify patients with confirmed cannabis use. We developed and tested an algorithm to identify outcomes of UDT results for cannabis because there is wide variability in reporting methodology, including in multi-site health systems. Among all patients receiving care in the Department of Veterans Affairs (VA) who were prescribed long-term opioid therapy for chronic pain, we identified a random sample who completed UDT for cannabis. Through an iterative process, we developed an algorithm to identify UDT cannabis results. Manual review of EHR data was conducted to verify accuracy of UDT results. The final UDT algorithm correctly identified 99% of cannabis positive UDT results and 100% of cannabis negative UDT results among 200 randomly sampled patients. Study findings suggest a high degree of accuracy for using an algorithm to identify samples of patients with positive cannabis UDT results across multiple institutions with disparate UDT reporting practices. The methodology for testing this algorithm is feasible and may be applied to other multi-site health systems.

This paper proposes amatrix-basedmodeling approach for analyzing spaceflight campaign logistics. A campaign is considered to be a series of coordinatedflights delivering cargo at a location or node. Amatrix representation of the cargo carried by flights for consumption in different time periods (or missions) is formulated. The matrix adopts specific structures based on the nature of the campaign, thereby allowing a quick visualization of the campaign logistics properties. A logistics strategy index is proposed for quantifying manifesting strategies, and a flight criticality index is defined to help in identifying important flights from a cargo-delivery perspective and aid in assessing impact of flight cancellations, failures, and delays. The method is demonstrated on a lunar outpost establishment and is also applied in modeling the logistics of the International Space Station. Amanifest (M) matrix and flight dependency (D) matrix is created for crew provisions cargo delivered to the ISS over a period of 10 years. It is found that the overall logistics strategy index for crew provisions has so far been 0.85 (meaning 85% of the crew provisions cargo is prepositioned on average for each mission) and that the prepositioning is for up to a maximum of four future missions at a time.

The Distiller Calcium Limiter (DCaL) system was designed to remove calcium scale constituents from urine. The DCaL is based on a process called electrodialysis. In electrodialysis, water is desalinated by the transport of ions through ion exchange membranes under the driving force of an electric potential between a cathode and an anode. The DCaL system uses electrodialysis with ion replacement where ions of insoluble inorganic salts, such as CaSO4, exchange cations (Ca) or anions (SO4) with soluble salts, such as NaCl (Na and Cl), to prevent the precipitation of inorganic solids. Removal of calcium from urine is particularly important for spacecraft wastewater treatment systems due to the precipitation of calcium scale solids on heat transfer surfaces. Operation of the International Space Station (ISS) Urine Processor Assembly (UPA) has demonstrated that calcium-based scale is the limiting factor to achieving high water recovery ratios. The DCaL process removes calcium, which would ultimately prevent calcium-based precipitation from occurring and subsequently the formation of calcium scale. The objective of this study was to evaluate the effectiveness of the DCaL system in removing calcium scale precursors from spacecraft wastewater (a urine-based solution). Three pretreatment methods were tested including: the US ISS pretreatment (sulfuric acid and Oxone), AES pretreatment (Bronopol PESTANAL and maleic acid) as well as the US/Russian Chromic Acid ISS pretreatment. The results indicated that the DCaL system does remove calcium scale constituents and could enable a distillation system to achieve a water recovery ratio above 85%; however, the pretreatment method, operating conditions (production rate and feed pH), and fouling of the membrane play an important role in system performance.

*† ‡ This paper provides a cost-benefit analysis for a real-time, autonomous inventory management system for the International Space Station (ISS) based upon Radio Frequency Identification (RFID) technology. This paper describes a Net Present Value (NPV) analysis of a possible application of the system to the International Space Station’s cargo transfer bags. Quantities such as crew time, cargo launch volume, and cargo launch mass were monetized to allow comparison of costs and benefits, and several different implementation scenarios were evaluated. The analysis found that the application has marginal or negative value under conservative assumptions, but possibly significant positive value when inventory transactions are concentrated in a subset of the total cargo transfer bag population, and/or if ISS Operations are continued into 2018/2020. We show that a modest concentration of inventory transactions – for example, 75% of transactions occurring in the 50% of the bags that are RFID equipped - results in a positive mean NPV of approximately $46.8 million, and an 84% probability of a positive NPV. Also, a gradual Phase-In Implementation Scenario – as it is modeled in this work – is inferior to a more rapid deployment of the system via Modification Kits.

As NASA looks ahead to next-generation human space exploration, it is essential to consider the cost of operations and support in order to ensure the development of affordable programs. The life-cycle costs of future exploration ventures can be reduced by focusing on the interplanetary logistics strategy. By leveraging proven supply chain management techniques from the military and commercial sectors and applying them to the unique challenges of human space exploration, space logistics can be streamlined, and mission affordability and robustness can be increased. This paper describes a modeling framework for space logistics which enables description, evaluation, and optimization of various types of logistics strategies. The framework is embodied in SpaceNet, a discrete event simulation and optimization software program.

Space agencies around the world are gearing up for new human space exploration missions. In order to ensure that such programs are sustainable, it is worthwhile to examine the lessons learned from past experiences with space logistics and supply chain management. This paper offers an overview of the current state of the art in logistics management for space exploration focused on information systems, and highlights some emerging technologies that have the potential to significantly improve both the study and operation of space logistics systems.

*† ‡ § ** Mission planners for future human space exploration enterprises face several challenges in the area of operations, including coordinating the logistics and resupply of far-flung planetary bases. A number of logistics methods have been perfected by commercial and military experts, but these are not well understood in the context of space exploration. This paper describes a field expedition to a Mars analog site in the high Arctic, at which terrestrial logistics methods were tested in the context of (analog) planetary exploration. A comprehensive comparison is drawn between the logistics scenarios at HMP and a potential lunar or Mars base, in order to determine the extent of the analogy between them. It appears that the analogy is quite good in certain categories of supplies and shipment, but breaks down in others. When certain straightforward differences are accounted for, the data gathered from HMP can be used to validate and inform planetary base logistics models in support of future human lunar and Mars exploration.

The International Space Station (ISS) has served an important role in providing essential experience and know-how for space operations that will benefit future exploration missions. This paper analyzes the logistics of the ISS using matrix based methods. A manifest (M) matrix and flight dependency (D) matrix is created for crew provisions cargo delivered to the ISS over a period of ten years. It is found that the overall Logistics Strategy Index for crew provisions has so far been 0.85 (meaning 85% of the crew provisions cargo is pre-positioned on average for each mission) and that the prepositioning is for up to a maximum of four future missions at a time.