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Objectives: To prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program.Setting: VHA's OEND program sought national implementation of OEND across all medical facilities (n = 142).Practice Description: This paper describes VHA's efforts to facilitate nationwide health care system-based OEND implementation, including the critical roles of VHA's national pharmacy services and academic detailing services.Practice Innovation: VHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system-based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools).Evaluation: Clinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND.Results: Through fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions.Conclusion: VHA has successfully translated community-based OEND into health care system-based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA's experience implementing this novel health care innovation nationwide. [ABSTRACT FROM AUTHOR]

This report examines whether long-term care facilities should implement policies and procedures to support advance care planning by proxy for residents who lack decision-making capacity. The report focuses on advance care planning in the Department of Veterans Affairs. After reviewing clinical, legal, and ethical perspectives, the authors conclude that advance proxy planning is ethically sound and can improve patient care. However, because experience with advance proxy planning is still fairly limited, the authors do not recommend that a particular standardized approach be mandated at the national level. Instead, local facilities are advised to develop their own policies and then evaluate their effect. The report contains specific recommendations for the advance proxy planning process. [ABSTRACT FROM AUTHOR]

Introduction: The 2021 update to the United States Preventive Services Task Force guidelines for lung cancer screening (LCS) aims to reduce disparities derived from sex, race/ethnicity, and socioeconomic status. Few studies have addressed adherence to LCS among female Veterans. Methods: To evaluate differences in adherence to LCS by sex, we conducted a retrospective cohort study within the VA Connecticut LCS Program between June 2013 and March 2020. Our primary outcome was nonadherence, defined as lack of completion of a chest CT scan within the guideline recommended interval plus a 90-day grace period. Eligible patients were enrolled in the screening program and had a baseline Lung-RADS score of 1, 2, or 3. Patients with Lung-Reporting and Data System (RADS) 4 were excluded due to variability in follow-up recommendations. We adjusted for age, race, smoking history, mental/medical comorbidities, and primary care (PC) visits (1-year after first/index CT). Logistic regression modeling was used to determine associations between sex and nonadherence overall and stratified by Lung-RADS 1-2 and Lung-RADS 3. Results: Among 4,711 Veterans, the overall rate of nonadherence was 34%. Female Veterans were 66% more likely nonadherent to follow-up (odds ratio [OR] = 1.66, confidence interval [CI] = 1.19-2.30) compared with male Veterans. Substance use disorder was associated with greater nonadherence (OR = 1.22, CI = 1.01-1.47). Lower nonadherence was observed among patients with COPD (OR = 0.77, CI = 0.66-0.9) and PC engagement (OR for nonadherence with 5 or more PC visits = 0.78, CI = 0.67-0.91). The associations between sex and nonadherence were similar in models stratified by Lung-RADS groups 1-2, although did not reach significance for the Lung-RADS 3 group. Discussion: In this cohort, female Veterans were more likely nonadherent. More work is needed to understand the distinct barriers to LCS follow-up among female Veterans. Health care system engagement significantly reduced nonadherence, which may partially explain higher rates of nonadherence among female Veterans who had fewer medical comorbidities.

Background: Aligned with increasing organizational and policy focus on whole person care, particularly for patients with multimorbidity, health systems are operationalizing how to assess what patients find meaningful in life for personalized health planning. Few studies have examined how patients with multimorbidity at high risk of adverse events perceive connections between what is most important in life (i.e., personal values) and health, healthcare, and healthcare decisions. This knowledge is critical to optimizing how, when, and under what circumstances the topics are addressed in healthcare settings., Objective: To understand how high-risk patients with multimorbidity perceive connections between personal values and health, healthcare, and healthcare decisions., Design: Qualitative study., Participants: Patients ≥ 75th percentile risk of hospitalization or mortality using a validated prediction score, with ≥ 2 diagnoses among depression, hypertension, chronic kidney disease, or diabetes, engaged in Veterans Health Administration primary care., Approach: Individual semi-structured telephone interview, analyzed with content analysis., Key Results: Patients (N=27) averaged 68 years old; 17 (63%) were male. Three main themes emerged: (1) personal values were rarely discussed in healthcare settings or reflected in healthcare decision-making, sometimes given perceived lower relevance by patients; (2) when personal values were perceived as affecting health decisions, it was within specific contexts or circumstances (e.g., deciding on surgery); (3) eliciting personal values in healthcare settings could have positive or negative consequences, related to conditions of disclosure and resultant action taken in the care plan, and not all patients wanted to disclose values., Conclusions: In this study, high-risk patients with multimorbidity reported rarely discussing values in healthcare settings, and if so, only perceived relevant connections between values and health in specific contexts. While some participants felt sharing values benefitted care, not all felt comfortable with disclosure. Patient preferences for eliciting and incorporating values are relevant to integrating patient personal values in healthcare settings., Competing Interests: Declarations. Conflict of Interest: The authors declare that they do not have a conflict of interest., (© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The purpose of this RESNA Position Paper is to provide evidence from the literature and share typical clinical applications supporting the application of ultralight manual wheelchairs (ULWCs) to assist practitioners in decision-making and justification of wheelchair recommendations.

Substance use disorder (SUD) residential treatment provides critical services to patients with complex clinical needs. The Department of Veterans Affairs (VA) has over 70 SUD residential programs to meet the needs of veterans with severe SUD. Prior research is mixed on what SUD residential length of stay (LOS) duration maximizes average treatment outcomes, with some studies advocating for around 30 days and others advocating for at least 90 days. Much of this research is limited by methodological issues and fails to consider both outcomes for established patients and timely access for prospective patients. The present study sought to clarify the relative benefits of different LOSs to be considered by SUD residential program decision-makers as default LOSs, upon which to be personalized by individual patient needs and clinical assessment. Using medical record data associated with N = 15,889 veterans discharging from a VA SUD residential center between 10/1/2021 and 9/30/2022, we identified an optimal LOS range balancing average treatment outcomes and ensuring new patient access/minimizing established patient diminished returns from treatment. Using a generalized propensity-weighted dose-response curve, we identified key LOSs between 35 and 49 days with different tradeoffs between enhancing outcomes and access., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: All manuscript authors are employed by the Department of Veterans Affairs. All manuscript authors used equipment (i.e., computer access) involved in the development of this study., (Published by Elsevier B.V.)

Competing Interests: Disclosure The following authors disclosed financial relationships: P. Hosseini-Carroll: Advisory board and speaker for Janssen. R. B. Issaka: Consultant for Guardant Health, Inc. F. P. May: Consultant for Exact Sciences, Medtronic, Geneoscopy, Freenome, Guardant, and Natura. D. K. Rex: Research support from Boston Scientific and Olympus America Corp; consultant for Olympus America and Exact Sciences; honoraria from Sebela Pharmaceuticals, Boston Scientific, and Laborie Medical Technologies. J. A. Christie: Consultant for Olympus America; advisory board for Takeda Pharmaceuticals and Neurogastrx Inc. All other authors disclosed no financial relationships. Research support for this study was provided by an unrestricted grant from Exact Sciences, with additional support from Ironwood Pharmaceuticals and Braintree, A Part of Sebela Pharmaceuticals.

Objective: Although thyroid tumors possessing isolated RAS mutations are generally considered to be indolent, the oncologic outcomes of tumors evaluated with comprehensive molecular testing have not been well characterized., Methods: We performed a retrospective cohort study of 368 consecutive patients with Bethesda III-VI thyroid nodules at a single institution (2016-2021) who underwent molecular testing with ThyroSeq v3. Patients with isolated RAS mutations were identified, and those with isolated BRAF V600E-mutated cancers were used as comparators. Outcomes of interest included rate of malignancy, high-risk histopathologic features, and structural disease recurrence., Results: A total of 50 patients (14%) had an isolated RAS-mutated nodule, of whom 41 underwent surgery (median age, 43 years; female, 83%). The malignancy rate on final pathology was 46%, whereas 32% of patients had noninvasive follicular thyroid neoplasm with papillary-like nuclear features and 22% had benign histopathology. In comparison, the isolated BRAF-mutated cohort (86 [24%] patients; median age, 45 years; female, 68%) had a 100% rate of malignancy. Only 2 (11%) of the isolated RAS patients with malignant histopathology had lymph node metastasis, compared with 34 (39%) of the BRAF cohort (P = .016). Over a median follow-up of 5 years, no patients with isolated RAS mutations had a structural recurrence compared with 5 patients (6%) in the isolated BRAF cohort., Conclusion: Bethesda III-VI thyroid nodules with isolated RAS mutations have a low rate of aggressive histopathologic features and are unlikely to recur. Thyroid lobectomy may be sufficient treatment for these tumors., Competing Interests: Disclosure The authors have no conflicts of interest to disclose., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

Aim: To examine nurse workplace bullying relative to diverse sexual orientation and gender identity groups., Design: Observational cross-sectional study., Methods: Using an annual organisational satisfaction survey from 2022, we identified free-text comments provided by nurses (N = 25,337). We identified and themed comments for specific bullying content among unique respondents (n = 1432). We also examined close-ended questions that captured organisational constructs, such as job satisfaction and burnout. We looked at differences by comparing diverse sexual orientation and gender identity groups to the majority using both qualitative and quantitative data., Results: For the free-text comments, themed categories reflected the type of bullying, the perpetrator and perceived impact. Disrespect was the most frequent theme with supervisors being the primary perpetrator. The reported bullying themes and workplace perceptions differed between nurses in the diverse gender identity and sexual orientation group compared to other groups. Nurses who reported bullying also reported higher turnover intent, burnout, lower workplace civility, more dissatisfaction and lower self-authenticity., Conclusion: Diverse sexual orientation and gender identity groups are understudied in the nurse bullying research, likely because of sensitivities around identification. Our design enabled anonymous assessment of these groups. We suggest practices to help alleviate and mitigate the prevalence of bullying in nursing., Patient or Public Contribution: No Patient or Public Contribution., Impact: We examined differences in perceptions of nurse bullying between diverse sexual orientation and gender identity groups compared to majority groups. Group differences were found both for thematic qualitative content and workplace experience ratings with members of minority groups reporting less favourable workplace experiences. Nurse leaders and staff can benefit from learning about best practices to eliminate bullying among this population., Reporting Method: STROBE guidelines for cross-sectional observational studies., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Objectives. To distinguish differences in physical and mental health between transgender and gender-diverse (TGD) veterans identified via diagnostic codes, self-identification, and their combination. Methods. We used sociodemographic characteristics and physical and mental health diagnoses for TGD veterans receiving care in Veterans Health Administration (VHA). Results. Among the cohort of 12 745 TGD veterans, 69.3% were identified solely using self-reported gender identity data, 23.4% were identified using only TGD-related diagnostic codes, and 7.2% had both TGD-related diagnostic codes and gender identity data in their medical record. TGD veterans identified using self-reported gender identity data were younger and more racially and ethnically diverse compared with those identified with only diagnostic codes. Across nearly all independently examined health conditions, TGD veterans identified via self-reported gender identity were at lower risk compared with those identified via diagnostic codes. Conclusions. Inferences drawn from studies of TGD veteran health may be significantly impacted by choice of methodology for defining the TGD veteran cohort. New analyses using self-reported gender identity data, as opposed to diagnostic codes, are critical to understand the health of this population within VHA. ( Am J Public Health . 2025;115(3):403-413. https://doi.org/10.2105/AJPH.2024.307920).

Background/objective: The Centers for Medicare & Medicaid Services (CMS) Overall Hospital Quality Star Rating, established in 2016, is a summary of publicly available quality information for acute care hospitals. In July 2023, Veterans Health Administration (VHA) hospitals became eligible to receive a CMS Overall Hospital Quality Star Rating for the first time. Our objective was to compare performance in quality ratings among VHA and non-VHA hospitals., Methods: We used the hospital quality measure scores posted to Care Compare on Medicare.gov as of January 2023 as our primary data set. We conducted a pair of analyses to characterize the performance of VHA hospitals compared to non-VHA hospitals: an overall analysis including all rated hospitals, and a matched analysis in which only a single nearby hospital was included for each VHA hospital., Results: Of the 4518 non-VHA hospitals, 2962 (65.6%) received a Star Rating, compared to 114 (84%) of 136 VHA hospitals. VHA hospitals tended to receive higher ratings overall (one-star: 8%; two-star: 11%; three-star: 14%; four-star: 35%; five-star: 32%) than non-VHA (one-star: 8%; two-star: 22%; three-star: 29%; four-star: 26%; five-star: 15%). A similar pattern was observed in the matched analysis., Conclusions: VHA hospitals tended to perform better on the Overall Star Rating compared to non-VHA hospitals, as evidenced by being more likely to receive a four- or five-star rating. The eligibility of VHA hospitals to receive an Overall Star Rating signifies an important addition to the program that will allow Veterans to make more informed healthcare decisions., (© 2024 The Author(s). Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

Purpose of Review: Climate change has been implicated as the driver for the increasing number, intensity, duration, and consequences of catastrophic weather events. As a result of extreme weather events, climate change has also been implicated as an important mediator of adverse kidney health outcomes, not only increasing the risk for the development of acute and chronic kidney diseases, but also disrupting the delivery of critical kidney health services. In particular, the delivery of dialysis services during major emergencies remains an ongoing and increasing problem, with a recognized need for improved emergency preparedness and disaster management (EP-DM) strategies to mitigate the increased risk of morbidity and mortality associated with missed dialysis treatment., Recent Findings: There are increasing reports detailing the challenges of kidney dialysis care in times of crisis, to include those resulting from both man-made and natural disasters. Optimized management of the high-risk vulnerable dialysis patient population must include both facility-facing comprehensive continuity of operations and emergency response plans, and ongoing patient-facing emergency preparedness education., Summary: This review discusses the adverse impact of climate change-related natural disasters on the delivery of dialysis services, and the evolving EP-DM strategies developed and implemented by the Veterans Health Administration (VA) to optimize the care and well being of the vulnerable end stage kidney disease (ESKD) patient population., (Copyright © Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Housing instability is a known barrier to healthcare utilization potentially affecting the prevention, diagnosis and treatment of chronic diseases among diverse groups of adults. We examined the intersection of recent housing instability with prevalent cardiovascular disease, diabetes, cancer and psychiatric diagnoses among aging adults., Methods: Cross-sectional data on 147 465 participants of the 'All of Us' Research Program (6 May 2018-1 July 2022), ≥50 years of age at enrollment, were analyzed. Self-reported housing instability over the past 6 months was examined in relation to diagnosed conditions at age ≥50 years based on electronic health records. Multivariable logistic regression models sequentially adjusting for demographic and socioeconomic characteristics were constructed to estimate odds ratios (OR) with their 95% confidence intervals (CI)., Results: After adjusting for confounders, past 6 months housing instability was associated with lower odds of diagnosed cardiovascular disease (OR = 0.89, 95% CI: 0.87, 0.93) and cancer (OR = 0.82, 95% CI: 0.78, 0.86), higher odds of diagnosed psychiatric (OR = 1.35, 95% CI: 1.30, 1.40) conditions, but was unrelated to diagnosed diabetes (OR = 0.98, 95% CI: 0.94, 1.01)., Conclusions: Recent housing instability among aging adults is positively associated with psychiatric diagnoses, but negatively associated with cardiovascular and cancer diagnoses, with implications for chronic disease prevention., (© The Author(s) 2024. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Binge alcohol use is increasing among aged adults (>65 years). Alcohol-related toxicity in aged adults is associated with neurodegeneration, yet the molecular underpinnings of this age-related sensitivity to alcohol are not well described. Studies utilizing rodent models of neurodegenerative disease reveal heightened activation of Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and Nod like receptor 3 (NLRP3) mediate microglia activation and associated neuronal injury. Our group, and others, have implicated hippocampal-resident microglia as key producers of inflammatory mediators, yet the link between inflammation and neurodegeneration has not been established in models of binge ethanol exposure and advanced age. Here, we report binge ethanol increased the proportion of NLRP3+ microglia in the hippocampus of aged (18-20 months) female C57BL/6N mice compared to young (3-4 months). In primary microglia, ethanol-induced expression of reactivity markers and NLRP3 inflammasome activation were more pronounced in microglia from aged mice compared to young. Using a NLRP3-specific inhibitor (OLT1177) and a novel brain-penetrant Nanoligomer that inhibits NF-κB and NLRP3 translation (SB_NI_112), we find ethanol-induced microglial reactivity can be attenuated by OLT1177 and SB_NI_112 in microglia from aged mice. In a model of intermittent binge ethanol exposure, SB_NI_112 prevented ethanol-mediated microglia reactivity, IL-1β production, and tau hyperphosphorylation in the hippocampus of aged mice. These data suggest early indicators of neurodegeneration occurring with advanced age and binge ethanol exposure are driven by NF-κB and NLRP3. Further investigation is warranted to explore the use of targeted immunosuppression via Nanoligomers to attenuate neuroinflammation after alcohol consumption in the aging populations., (© The Author(s) 2025. Published by Oxford University Press on behalf of Society for Leukocyte Biology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: Post-acute heart failure (HF) care presents significant management challenges, particularly among veterans with cognitive and behavioral impairments due to Alzheimer's disease and related dementias (AD/ADRD) or severe mental illness (SMI). We hypothesized that comorbid AD/ADRD and SMI would reduce the likelihood of discharge home following HF hospitalization. In addition, we explored how AD/ADRD and SMI influence discharge to Veterans Affairs (VA) Community Living Centers (CLCs) compared with Medicare Skilled Nursing Facilities (SNFs)., Design: Retrospective cohort study spanning January 1, 2011, to September 30, 2019., Setting and Participants: Veterans hospitalized with acute HF at VA hospitals (n = 291,117)., Methods: We examined VA administrative data from HF hospitalizations to assess how AD/ADRD and SMI impact post-hospital discharge location. Using diagnostic codes from the prior year, we stratified participants by the presence of AD/ADRD and/or SMI, then employed logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for discharge location, adjusted for demographics, comorbidities, and health care utilization., Results: Participants were predominantly older (mean age: 78.1 ± 11.1 years), male (97.5%), and self-identified as White (72.7%). Those with AD/ADRD alone (n = 16,212) or SMI alone (n = 33,194) outnumbered those with both conditions (n = 3612). Compared with neither condition, the presence of AD/ADRD alone (adjusted OR [aOR], 0.523; 95% CI, 0.505-0.542), SMI alone (aOR, 0.869; 95% CI, 0.843-0.896), and both conditions (aOR, 0.505; 95% CI, 0.47-0.542) all reduced likelihood of discharge home. Participants with AD/ADRD and SMI were more likely to be discharged to a CLC than an SNF (aOR, 1.225; 95% CI, 1.064-1.411)., Conclusions and Implications: Our findings indicate that AD/ADRD and SMI are major barriers to discharge home for patients with HF, suggesting a need for enhanced supervision during health care transitions. This study calls for further research into how discharge location affects short- and long-term clinical outcomes in patients with cognitive and behavioral impairment., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2025. Published by Elsevier Inc.)

Background: Lung cancer screening (LCS) is recommended for asymptomatic patients. Administrative codes for LCS may capture tests prompted by signs/symptoms., Objective: To validate an automated algorithm that identifies LCS among asymptomatic patients., Design: In this cross-sectional study, an algorithm was iteratively developed to identify outpatient low-dose chest CT scans via Current Procedural Terminology (CPT) codes, search free text of radiology orders for screening terms and signs/symptoms (e.g., cough), and classify scans as screening or not., Participants: National population-based sample of 4503 adults ages 65-80 in Veterans Health Affairs primary care, with detailed smoking history to identify LCS-eligible individuals (30 + pack-years, current tobacco use, or quit < 15 years prior)., Main Measures: Algorithm specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) relative to manual chart review (gold standard) on 100% of screening scans and > 10% random sample of non-screening scans., Key Results: Chart review was conducted on n = 335 scans. The final algorithm could not classify 22% of scans, of which 73% were non-screening; these were excluded from primary analyses. Among 842 LCS-eligible individuals, the algorithm demonstrated 97% sensitivity (95%CI 91-99%) and 79% specificity (58-93%). Only 69% (61-77%) of scans classified as LCS via administrative codes were truly screening, compared to 95% of those classified as screening via the algorithm (p < 0.001). Algorithm performance was similar regardless of LCS eligibility, with 90% PPV (84-94%) and 93% NPV (86-97%) in the overall population regardless of tobacco cigarette history., Conclusions: An automated algorithm can accurately identify screening versus diagnostic chest imaging, a necessary step to unbiased analyses of LCS in non-randomized settings. Studies should assess the accuracy of administrative codes for LCS in other health systems., Competing Interests: Declarations. Conflict of Interest: The authors declare that they do not have a conflict of interest. Disclaimer: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. The opinions, findings, and conclusions presented herein represent those of the authors and not necessarily those of their employers or funders., (© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: While facilitation is a widely used implementation strategy with proven effectiveness, the development of the facilitator-recipient relationship, i.e., working alliance, has received limited attention. However, we hypothesize that working alliance may be part of the mechanism by which facilitation activates change. This study aimed to examine the associations between working alliance, facilitation, and change in clinical care in a hybrid type 3 trial of a manualized intervention, Getting to Implementation (GTI)., Methods: This concurrent triangulation mixed-methods study was conducted at 12 sites in a stepped-wedge trial. We collected surveys using the Working Alliance Inventory-Short instrument (WAI), which includes three subscales of goal alignment, task alignment, and affective bond, from three respondent types (clinical facilitator, evaluation facilitator, and site team members) after a year of intervention. Facilitation activity type and dose were tracked. Summative qualitative interviews with site champions and facilitators) elicited perceptions on working alliance, facilitation, and experiences with the intervention, and results were triangulated with statistical bivariate analyses. The associations between WAI and facilitation time, fidelity, and change in liver cancer screening rate (the primary trial outcome) were assessed., Results: Across 12 sites, facilitators and site team members completed 21 interviews and 40 WAI surveys, with site aggregate average working alliance scores of 5.9 ± 0.4 on a seven-point scale. Bond scores were highest (6.1 ± 0.5), followed by Goal (6.0 ± 0.4) and Task (5.8 ± 0.5) scores. Overall and subscale scores differed by respondent type, with site respondents consistently rating items higher than facilitators, particularly in Task items. Fidelity to the GTI process (e.g., timely completion of steps and tools) was significantly positively associated with WAI scores overall (r = 0.41, p = 0.007) and subscale scores, including Goal (r = 0.39, p = 0.011), Task (r = 0.42, p = 0.006), and Bond (r = 0.33, p = 0.039). WAI scores were not correlated with facilitation time (dose). WAI scores overall and the Bond and Goal scores were significantly positively associated with sustained improvement in cancer screening rates (r = 0.57, p = 0.015)., Conclusions: In this implementation trial, working alliance between site teams and facilitators was positively associated with both fidelity and cancer screening outcomes and was notably independent of time spent providing facilitation. Findings highlight the importance of working alliance in implementation studies., Trial Registration: This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20., Competing Interests: Declarations. Ethics approval and consent to participate: Per regulations outlined in VA Program Guide 1200.21, this project was deemed a non-research operations activity. Consent for publication: N/A. Competing interests: The authors declare that they have no competing interests., (© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Graduate medical trainees are positioned to experience high rates of negative well-being due to the demanding and hierarchical nature of this time in their careers. Focusing on the well-being of physician trainees is required to ensure a better future of medicine. A novel avenue of examining physician trainee well-being is through understanding the effects of moral injury and discrimination trauma in overall well-being., Objective: This secondary data analysis examines the moderating role of discrimination trauma and moral injury on six well-being metrics cross-sectionally at baseline and 4 months postcoaching intervention, respectively., Design: This is a secondary, cross-sectional analysis using survey data collected at two time points., Participants: The participants in this study (n = 1017) are women physician trainees in the USA., Main Measures: The predictor measures are as follows: Moral Injury Symptom Scale- Healthcare Providers and Trauma Symptoms of Discrimination Scale. The outcome measures are as follows: Maslach's Burnout Inventory, Young Impostor Scale, Self-Compassion Scale, and Secure Flourishing Index., Key Results: At baseline, discrimination trauma moderates the relationship among moral injury with impostor syndrome and self-compassion. After the coaching intervention, moral injury moderates the effect of the intervention on impostor syndrome., Conclusions: The results of this secondary analysis emphasize the role moral injury and discrimination play in overall well-being, specifically through the experiences of self-compassion and impostor syndrome. This study calls for early measurement and mitigation efforts of both moral injury and discrimination trauma, which may effect well-being for graduate medical trainees and lessen the impact of our coaching intervention., Competing Interests: Declarations:. Conflict of Interest:: There are no conflicts of interest to report for this manuscript. Disclaimer:: Drs. Fainstad and Mann are professional coaches, and do not coach clients outside of their academic roles. The BT program is owned and delivered by the University of Colorado (CU), a not-for-profit school of medicine. Drs. Fainstad and Mann have not and do not plan to personally receive any financial support (i.e., no royalties or consulting fees) outside of their CU faculty salaries to create or deliver this program., (© 2025. The Author(s), under exclusive licence to Society of General Internal Medicine.)

High reliability organizations in healthcare are responsible for consistently maintaining high levels of safety and quality over extended periods of time and across multiples service lines and settings. In order to accomplish this, transparent and bi-directional communication across service lines and teams with organizational leaders is essential. Leader rounding for high reliability helps to ensure effective communication takes place. Developing and implementing an evidence-based process for leader rounding for high reliability is important as is determining effectiveness over time. We describe an initiative for assessing effectiveness after an evidence-based process for leader rounding for high reliability was created and implemented for the Veterans Affairs Bedford Healthcare System., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Persons with HIV (PWH) on contemporary antiretroviral therapy (ART) are at elevated risk for developing age-related cardiometabolic diseases. We hypothesized that integrative analysis of cross-tissue, multimodal data from PWH could provide insight into molecular programming that defines cardiometabolic phenotypes in this high-risk group., Methods: We enrolled 93 PWH without diabetes who were virologically suppressed on contemporary ART and obtained measures of insulin resistance, glucose intolerance, and adiposity. We performed circulating lipidomics, proteomics, and metabolomics, as well as subcutaneous adipose tissue (SAT) bulk transcriptomics, and used multiomics factor analysis (MOFA) to perform integrative analyses of these datasets., Results: The median age was 43 years, median body mass index 30.8 kg/m2, 81% were male, and 56% were self-identified non-Hispanic White. We identified a specific MOFA factor associated with visceral adipose tissue volume (ρ = -0.43), homeostasis model assessment 2 insulin resistance score (ρ = -0.52), liver density (ρ = 0.43), and other cardiometabolic risk factors, which explained more variance in the SAT transcriptome and circulating lipidome compared with the circulating proteome and metabolome. Gene set enrichment analysis of this factor showed extracellular matrix and inflammatory pathways that primarily mapped to SAT myeloid cells and adipose progenitor cells using single-cell deconvolution. Lipidomic analysis showed that this factor was significantly enriched for triacylglycerol and diacylglycerol species., Conclusions: Our multiomic analysis demonstrated coordinated, multitissue molecular reprogramming in virologically suppressed PWH with elevated cardiometabolic disease risk. Longitudinal studies of PWH with assessments of adipose tissue and lipid handling are necessary to understand mechanisms of cardiometabolic disease in PWH. Clinical Trials Registration. NCT04451980., Competing Interests: Potential conflicts of interest. J. R. K serves as a consultant to Merck & Co, Gilead Sciences, Janssen Pharmaceuticals, and Theratechnologies; and receives grant support from Merck & Co and Gilead Sciences. R. S. has served as a consultant for Amgen and Cytokinetics; and is a coinventor on a patent for ex-RNAs signatures of cardiac remodeling and a pending patent on proteomic signatures of fitness and lung and liver diseases. A. S. P. has patents pending on proteomic signatures of fitness, lung, and liver disease. J. A. K. reports grants/contracts from Boehringer Ingelheim; and scientific advisory board membership at APIE Therapeutics and Arda Therapeutics. C. N. W. serves as a consultant to Merck & Co and Gilead Sciences; and receives grant support from Gilead Sciences. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Patients who have experienced an inpatient hospitalization for heart failure are at increased risk of mortality, particularly during the months following discharge. This study described patient characteristics associated with suicide death and examined the time course of death by suicide compared to that of other types of death amongst patients with a recent medical hospitalization for heart failure., Method: Using Department of Veterans Affairs (VA) electronic medical records from 2011 to 2020, we identified a cohort of Veterans hospitalized with a heart failure diagnosis who died after discharge. We merged the VA Mortality Database Record, a compilation of death sources and causes, with the VA electronic health record and compared characteristics of Veterans who died by suicide and by other causes., Results: In the cohort of 348,840 Veterans, 1,097 died by suicide and 347,743 died by other causes. Compared to those who died by other causes, Veterans who died by suicide were, on average, younger, had fewer comorbidities, more likely to have a depression diagnosis, more likely to be White, and had lower prior year healthcare costs (Standardized mean differences [SMD] ranged from 0.25 to 0.46). Unadjusted analyses showed longer length of time between hospital discharge and death for those who died by suicide compared to other causes (SMD = 0.18); however, analyses adjusting for comorbidities revealed no difference in time to death between those who died by suicide versus other causes., Conclusions: Demographic, clinical, and healthcare utilization characteristics distinguished Veterans with heart failure who died by suicide from those who died by other causes. Time to death following hospital discharge did not differ between groups when accounting for relevant factors. Comprehensive suicide screening and intervention is needed following a heart-failure hospital discharge, particularly for Veterans at elevated risk., Competing Interests: DISCLOSURES The authors have no conflicts of interest to report., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Many transgender and gender-diverse (TGD) people experience significant barriers to health care access, facing disparities in care, limited payments for gender-affirming services, or insufficient training and knowledge among providers. Given validation studies reporting increasing rates of TGD-related status, we documented health care types used by TGD veterans to signal whether engagement in Veterans Health Administration (VHA) care increased or decreased following documentation of a TGD-related diagnosis code. Methods: The cohort was defined by receipt of a TGD-related diagnosis code in the VHA Corporate Data Warehouse from October 1, 1999, through September 30, 2021 (fiscal years 2000 through 2021). Data were summarized in two 1-year periods before and after TGD-related diagnosis. Logistic regression estimated predictors of VHA care post-TGD-related diagnosis as well as filling gender-affirming prescriptions in the VHA. Results: Over the 23-year study period, 9894 transgender veterans were identified. Among the 91% using VHA both before and after TGD diagnosis, visits for primary, specialty, and mental and behavioral health care increased whereas emergency care did not change. Factors associated with discontinuing VHA care were Black/African American and another race, married status, older age, and service in recent versus earlier eras. Younger, highly disabled from military service veterans and those in the West (vs. South) were more likely to fill gender-affirming prescriptions in the VHA. Conclusion: This study established high levels of disability and apparent willingness to continue with care in the VHA following establishment of TGD status. The role of interpersonal, provider, and policy in VHA retention remains to be examined.

Rodriguez-Nava et al . present a proof-of-concept study evaluating the use of a secure large language model (LLM) approved for healthcare data for retrospective identification of a specific healthcare-associated infection (HAI)-central line-associated bloodstream infections-from real patient data for the purposes of surveillance. 1 This study illustrates a promising direction for how LLMs can, at a minimum, semi-automate or streamline HAI surveillance activities.

The widespread adoption of next-generation sequencing technology in molecular pathology has enabled us to interrogate the genome as never before. The huge quantities of data generated by sequencing, the enormous complexity of human and microbial genetics, and the need for fast answers demand increasing use of automation as we diagnose disease and guide patient treatment. Much of this automation is based on tools that fall under umbrellas that have come to be known as machine learning and artificial intelligence. In this review, we outline some of the broad ideas that underpin these complex computational methods. We discuss the roles of pathologists and data scientists in generating new tools and factors to keep in mind when adopting these systems for use in molecular pathology. We give special attention to regulatory and professional society guidance for validating them in individual institutions and to possible sources of bias. Finally, we briefly discuss ongoing efforts in computer science that may dramatically impact artificial intelligence in the future., Competing Interests: Disclosure Statement None declared., (Copyright © 2025. Published by Elsevier Inc.)

Rationale: Many patients with chronic obstructive pulmonary disease (COPD) receive hypnotic prescriptions to mitigate insomnia symptoms. Although clinical practice guidelines advise short-term use, patients often receive these medications long-term. As patients with COPD may be more susceptible to adverse effects of hypnotics, it is critical that we better understand the incidence and potential influences of this practice., Objectives: To characterize the incidence and predictors of guideline-discordant long-term receipt of hypnotic medications among patients with COPD., Methods: Using nationwide Veterans Health Administration (VA) data, we identified patients with clinically diagnosed COPD from 2010-2019 without prior hypnotic receipt in the past year. To identify individuals with new hypnotic use, we restricted this sample to those who received at least 30 total days of zolpidem, melatonin, trazodone, and/or doxepin within a 90-day period. We defined long-term hypnotic receipt as continued availability of one of these hypnotic medications for at least 30 days within the subsequent 90-day period. We then used a mixed-effects logistic regression model to assess patient and site-level associations with long-term receipt., Results: Among 4,262 patients with COPD and new hypnotic receipt, 55.6% (2,371) continued to receive hypnotics long-term. Long-term receipt was positively associated with short-acting beta agonist (SABA) receipt (Every 10% increase in days with SABA availability, OR 1.03, 95%CI 1.02-1.05), maintenance inhaler prescriptions (monotherapy, OR 1.35, 95%CI 1.10-1.68, dual therapy, OR 1.43, 95%CI 1.20-1.70, triple therapy, OR 1.54, 95%CI 1.24-1.91), post-traumatic stress disorder (OR 1.21, 95%CI 1.02-1.44), major depressive disorder (OR 1.24, 95%CI 1.07-1.44), anxiety disorder (OR 1.21, 95%CI 1.03-1.44), and more frequent primary care visits (>5 visits in the past 12 months: OR 1.86, 95%CI 1.19-2.90). Long-term receipt was negatively associated with initial receipt of melatonin (OR 0.70, 95%CI 0.55-0.91) and more than one pulmonary visit in the prior 12 months (OR 0.74, 95% CI 0.56-0.97)., Conclusions: Despite guideline recommendations, long-term hypnotic receipt is common among patients with COPD. Future work to prevent long-term hypnotic prescriptions should consider the role that respiratory symptoms and mental health comorbidities may have in driving this practice.