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Health Services Research & Development

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Honoring Vietnam Veterans: 50th Anniversary

March 2018

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In 2017, President Trump signed the Vietnam War Recognition Act designating March 29 of each year as National Vietnam War Veterans Day. This is an opportunity for Americans to recognize, honor, and thank Vietnam Veterans for their service during one of the longest wars in our country’s history. The commemoration recognizes all men and women who served on active duty in the U.S. Armed Forces in Vietnam from November 1, 1955 to May 7, 1975. Nine million Americans, including 58,000 who lost their lives and approximately 7.2 million living today, served during that period.

HSR&D works to identify, evaluate, and implement evidence-based strategies that help the VA healthcare system provide optimal care for all Veterans. Following are just a few of the research studies that will benefit Veterans of the Vietnam era in particular.

PTSD in Vietnam Era Women Veterans

PTSD was the signature illness for men who served in Vietnam; however, far less is known regarding the effects of PTSD on women Veterans’ health. This study examined the prevalence of lifetime and current PTSD for women Veterans who served in the Vietnam era by wartime location, and the extent to which location was associated with PTSD. Using data from VA’s Health of Vietnam-Era Women’s Study (HealthVIEWS), investigators identified three cohorts: women Veterans who served in Vietnam, women Veterans who served near Vietnam (i.e., Japan, Guam, and the Philippines), and those who served in the U.S. Data for the study were collected by mail and telephone from 5/11 through 8/12 and included: 1,956 women Veterans who served in Vietnam, 657 women who served near Vietnam, and 1,606 women who served in the U.S. Findings show:

  • Women Veterans who served in Vietnam had significantly higher levels of lifetime and current PTSD than women who served near Vietnam or in the U.S.
  • The lifetime prevalence of PTSD was 20%, 12%, and 14% for the Vietnam, near Vietnam, and U.S. women Veterans, respectively. The prevalence of current PTSD was 16%, 8%, and 9% for these three cohorts, respectively.
  • The higher prevalence for women who served in Vietnam was accounted for by their wartime exposures. In particular, self-reported sexual discrimination or harrassment and performance pressure were related to both lifetime and current PTSD in these women.

Implications: Clinicians should be vigilant to symptoms of PTSD – even in aging women Veterans – and encourage them to seek appropriate treatment if warranted.  

Magruder K, Serpi T, Kimerling R, Kilbourne A, et al. Prevalence of post-traumatic stress disorder in Vietnam-era women Veterans. JAMA Psychiatry. 2015;72(11):1127-1134.

Evaluation of Glycemic Treatment for Older High-Risk Veterans

One in every four Veterans has diabetes, of whom 40% are 60-69 years of age (Vietnam era cohort), and about 25% are older than 70 years of age. Moreover, serious comorbid conditions are common (31%) even among younger (<65 years) Veterans.  The 2003 VA/DoD Diabetes Guidelines (Pogach, et al., 2004) were the first to recommend that target glycemic values should be individualized based upon factors such as life expectancy, comorbid conditions, patient preferences, and risk for serious hypoglycemia. Major guidelines, such as those from the American Geriatric Society, American Diabetes Association, and VA/DoD Guidelines (Conlin et al., 2017), are now in agreement. However, the current National Committee for Quality Assurance (NCQA) <8% A1c measure for persons 65-74 years of age has not been updated since 2008. It neither stratifies by insulin nor excludes patients with advanced diabetes complications or serious non-diabetes related or mental comorbid conditions. Moreover, there is also no recommendation to assess glycemic management in individuals with diabetes >75 years of age.

Funded through VA HSR&D’s Quality Enhancement Research Initiative (QUERI) the long-term objective of this project is to improve the appropriateness of glycemic performance measurement for older adults. Specific aims are to:

  • Develop technical specifications for clinical indicators of under- and over-treatment,
  • Assess variation at VA organizational levels (community-based outpatient clinics, facilities, and VISNs); and to
  • Work with operational partners to develop clinical indicators for over- and under-treatment that can be used to inform quality improvement, surveillance, and direct patient care.

Using VA data, investigators identified 435,078 patients on insulin or sulfonylurea for glycemic control in FY2012, and who received care at any of 130 VA facilities. Findings show:

  • Nearly half of the Veterans in this study were over-treated or under-treated, and therefore at risk for short-term harms.
  • Among older/sicker patients on sulfonylurea and/or insulin, over-treatment (<7%) was 2.2 fold more common than under-treatment (>9%).
  • There was significant facility-level variation, and even the best performers had more than a third of high-risk patients with out-of-range A1c levels.
  • Only 28% of patients were in an A1c range of 7.5%-8.5% that is “guideline concordant.”

Implications: Investigators recommend replacing the current <8% A1c measure for older adults on hypoglycemic agents with an out-of-range measure that more appropriately focuses physician action and better reflects "patient safety." It is consistent with the recommendation of the Department of Health and Human Services’ National Action Plan for Prevention of Adverse Drug Events-Diabetes Agents. This plan recommended that the <8% A1c measures for older adults be revisited because they do not exclude patients with significant comorbid conditions for whom higher targets would be appropriate according to newer guidelines; in addition, they do not stratify by medications (such as insulin) or address potential overtreatment in high-risk groups.

Publications: Pogach L, Tseng C, Soroka O, et al. A proposal for an out-of-range glycemic population health safety measure for older adults with diabetes. Diabetes Care. April 2017;40(4):518-525.

Characteristics Associated with Non-Fatal Suicide Attempts Involving Firearms

Of the approximately 22 Veteran suicides each day, only about five are completed by Veterans enrolled in the VA healthcare system. More than 1,250 Veterans who receive care at VA facilities attempt suicide each month, with 15% who survive these attempts making a repeat attempt within the next 12 months. Veterans are more likely to use firearms as a method for suicide, accounting for 67% of all Veteran suicides compared to 51% by the general population. However, factors that place a person at risk for – or protect a person from suicide are not well understood. This HSR&D study sought to:

  • Evaluate the context and characteristics of non-fatal suicide events involving firearms;
  • Identify facilitators and barriers to help-seeking and disclosure of intent prior to the event; and
  • Develop recommendations for reducing access to firearms during periods of extreme emotional distress.

Study investigators recruited Veterans admitted to a VA hospital within 72 hours of a serious suicidal ideation or attempt involving firearms in an effort to understand the characteristic factors involved in the attempt and the context in which it occurred. Fifteen Veterans were enrolled into the study over a 12-month period. Participating Veterans served in the OIF/OEF/OND conflicts and during the Vietnam Era. Characteristics of the Veterans that were assessed included their attitudes about firearms, cultural beliefs in firearm ownership, perceived connectedness to their family and environment, and their attitudes about seeking help. Investigators also examined Veterans’ access to and usage patterns with firearms, significant events, environment, and relationships. Study findings show:

  • Veterans most often stated that the use of a firearm was due to their familiarity with and known lethality associated with their use. However, many stated that other means had been used previously and would be considered if firearms were not available.
  • Veterans reported the importance of having family and/or friends as a support structure and all acknowledged the importance of seeking help and talking about their physical and mental health problems.
  • The majority (80%) of Veterans had participated in counseling sessions at some point in their lifetime, with 47% reporting participation within the year. However, most indicated that they had not talked to anyone about suicide. Participants reported that participating in the study interviews helped them feel less distressed.

Findings also show that most (67%) of the Veteran participants had attempted suicide and really hoped to die; 73% had recurring thoughts of killing themselves in the past year, and 40% indicated serious thoughts of killing themselves five or more times within the past year. Many Veterans (47%) indicated a likelihood of future reattempts. Overall, a majority (60%) of the Veterans felt like they did not belong, however, 54% felt that there were people that they could turn to in times of need. More than 60% reported that past stressful military experiences had a continued effect on them – and that they avoided situations or thoughts that reminded them of those experiences.

Implications: Results indicate that Veteran suicide attempts/ideations exist over a period of time, Veterans will opt for any means to complete a suicide, choose firearms because of their high lethality rate, and that suicide re-attempts are likely. While a sense of alienation was mentioned by the majority, social support had a preventive function during times of crisis.

Personalized Life Expectancy to Improve Care for Veterans with Prostate Cancer

Veterans receiving VA healthcare may have higher prostate cancer risk due to a family history, race, or exposure to toxins such as Agent Orange (Vietnam War Veterans) and burn pits (Iraq war Veterans). Prostate cancer is the most common male cancer, presents in older men that may have additional medical conditions, and often follows an indolent course. It is estimated that 60% of all prostate cancer cases represent an "over-diagnosis" of clinically insignificant tumors. For prostate cancer patients, "over-diagnosis" refers to the diagnosis of a disease process that would otherwise not go on to cause symptoms or death. Similarly, "over-treatment" refers to the treatment of prostate cancers that would not otherwise go on to cause symptoms or death.

This ongoing HSR&D study seeks to leverage the power of VA’s standardized electronic health record to generate personalized risk-adjusted life expectancy estimates. Investigators will use these estimates to provide critical information to inform prostate cancer screening and medical treatment decision-making. Specific aims include:

  • Developing highly personalized life expectancy estimates as a function of patient-level features including age, race/ethnicity, prior medical claims, disease severity, exposure, health habits, pharmacy, and laboratory data for Veterans with prostate cancer; and
  • Evaluating the appropriateness of prostate cancer care in VA among men with limited estimated life expectancy.

Investigators will use machine learning approaches to generate the best-fitting model of overall survival. Using the general and personalized life expectancy estimates, they also will estimate the over-diagnosis and over-treatment of prostate cancer in VA.

Implications: These efforts have the potential to deliver higher-quality prostate cancer care by treating patients most likely to benefit, while avoiding futile treatment and minimizing treatment-related side effects.

Integrating Tobacco, Drinking, and Depression into Stroke Tool

Veterans who have experienced a stroke are at risk for smoking, problem drinking, and depression; these behaviors/disorders are likely to decrease self-management and increase the risk of recurrent stroke. The Self-management TO Prevent (STOP) Stroke Tool is a reminder in VA’s computerized patient record system (CPRS) that prompts clinicians on clinical practice guidelines (CPGs) for secondary stroke prevention. In addition, STOP facilitates patient/provider shared decision-making and collaborative goal-setting around stroke risk factor management and patient self-management actions. The purpose of this pilot study – funded by HSR&D QUERI – was to integrate and test state-of-the art, evidence-based smoking, problem drinking, and depression modules for stroke patients as part of the STOP Stroke Tool.

In phase one of the study, investigators observed and obtained feedback from VA providers and Veterans on barriers and facilitators to using the new modules while interacting with the STOP Stroke Tool during a simulated clinic visit. After modifying the modules based on this feedback, phase two consisted of implementing the new modules by assessing 60-day reductions in smoking, problem drinking, and depression. Of the 42 participants at baseline, 26 responded to the 60-day follow up. The majority of participating Veterans served during the Vietnam Era (69%). Findings show:

  • On average, the number of cigarettes smoked at baseline was 15, which went down to 12 at follow-up. The proportion of study participants who reported that quitting smoking is very/extremely important went up from 78% at baseline to 84% at follow-up. The proportion of study participants who reported that they are very/extremely confident to stay quit smoking went up from 22% at baseline to 32% at follow-up.
  • The Alcohol Use Disorder Identification Test (AUDIT-C) was used to evaluate alcohol use/misuse. At baseline, the proportion of problem drinkers, defined as having an AUDIT-C score of 4 or more for males and 3 or more for females, was 29%, which was significantly reduced to 0% at follow up with all Veterans having an AUDIT-C score of less than 4.
  • The Patient Health Questionnaire (PHQ-9) was used to evaluate depression at baseline and follow up. The proportion of study participants with major depression, defined as having a PHQ-9 score of 10 or more, at baseline was 21% and at follow up was 31%.

Implications: It is feasible to integrate evidence-based interventions for smoking, problem drinking, and depression within the STOP Stroke Tool. While there were modest improvements in smoking and problem drinking in this small sample, more research is needed to determine the effectiveness of the intervention on patient outcomes.

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