Medical Care最新文献

Objective: To describe "What Matters" to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes.

Background: As part of the 4Ms framework, identifying "What Matters" has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED.

Methods: We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of "What Matters" (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models.

Results: Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38-0.83, P < 0.01) was associated with older adults not meeting their desired outcomes.

Conclusions: Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

Objective: To identify and describe research conducted on the implementation, validity, and utility of whole-person outcome measures administered during routine inpatient or outpatient care.

Background: Incorporating information about patients' overall health, health-related quality of life, and global well-being into health care delivery has the potential to increase referral rates, enhance doctor-patient communication, and improve the detection of untreated symptoms. Assessment of these whole-person outcomes during routine clinical care is of broad interest to health care providers and health systems.

Methods: We employed a scoping review design and searched Ovid MEDLINE, APA PsycINFO, and CINAHL for relevant English-language primary studies and systematic reviews published through November 13, 2023. Screening for inclusion and data abstraction were conducted by 1 investigator then checked by another. Study risks of bias and the strength of available evidence were not assessed.

Results: Of 1327 potentially relevant publications, 44 primary studies and 5 systematic reviews met eligibility criteria. Assessment of global well-being was comparatively less researched than overall health or health-related quality of life. Available research provided a range of perspectives on the performance, feasibility, acceptability, implementation, and clinical utility of whole-person outcome measures. No studies reported change in patient health or disease outcomes attributed to whole person outcome assessment (directly or through changes to care delivery).

Conclusions: Currently available evidence provides insights about the performance and implementation of whole-person outcome measures during routine clinical care, but no studies are available that examine the impact of assessing whole-person outcomes on clinical or patient outcomes.

Objective: Research has shown that psychosocial well-being in veterans, including financial status, is related to better clinical outcomes after leaving military service. The current study examines variables linking financial well-being to physical health in veterans and non-veterans and identifies financial variables related to veteran status.

Methods: We analyzed data from the nationally representative 2021 Survey of Household Economics and Decisionmaking conducted by the U.S. Federal Reserve Board and compared the responses of veterans (N = 1176) to a non-veteran sample matched by age, sex, education, race, ethnicity, and geographic region (N = 1176).

Results: Multivariable analyses revealed that although veterans and non-veterans were similar in many financial domains, veterans were more likely to spend money on the lottery and gambling, pay overdraft fees on bank accounts, and take out payday or pawn shop loans. Analyses showed over one-third (35%) of veterans reported credit card debt, significantly higher than non-veterans. In veterans and non-veterans, higher physical health ratings were related to higher income, lacking medical debt, living in a community of greater economic advantage, and having a rainy-day fund in case of financial emergencies. Ratings of one's credit score were also significantly associated with ratings of one's physical health, in both veterans and non-veterans.

Conclusions: The data pinpoint specific financial domains to inform policy, education, and outreach aimed at improving veterans' psychosocial well-being. The results also reveal that individual and environment-level financial variables were related to physical health in this national survey, demonstrating the value of assessing financial well-being in the context of medical care, for both veteran and non-veteran patients.

Objectives: In 2023, the U.S. Veterans Health Administration convened a State of the Art meeting to evaluate the existing evidence and make recommendations for measuring the well-being of the whole person in clinical care, health research, and population health evaluation. In this article, we describe findings and recommendations concerning each of these health care system functions, as well as key takeaways from the meeting as a whole.

Background: There has been a growing call for health care organizations to expand their focus beyond disease-based concepts to consider both positive aspects of health and indicators of well-being that extend beyond the health domain. Yet, knowledge remains limited regarding how best to integrate these types of measurements in clinical care, health research, and population health evaluation efforts.

Method: State of the Art activities were organized into 3 workstreams, each focused on a core health care system function (clinical care, health research, and population health evaluation). Drawing from existing literature on the measurement of the well-being of the whole person in the assigned health care function, workgroups evaluated the existing state of knowledge and made recommendations for future work on well-being measurement in the health care setting.

Results: Cross-cutting themes included: (1) difficulty evaluating the current state of knowledge due to varied use of terminology in this literature; (2) appreciation for the value of well-being measurement in each health care function; (3) need for additional research on the use and benefits of well-being measures, including their role as predictors and moderators of health and health care outcomes; (4) importance of ensuring that measures are applicable for diverse patient groups and adequately reflect the "patient voice;" and (5) need for additional leadership investment and resource allocation to support use of these measures in the health care setting.

Conclusions: Knowledge from this meeting can be applied to enhance the use and application of measurement of well-being to improve patients' health and health care outcomes.

The Department of Veteran Affairs (VA) has an increased interest in addressing the well-being and whole health of Veterans. In March of 2023, the VA convened a conference to discuss whole-person outcomes of relevance for Veterans in clinical, research, and population health areas. Based upon perceptions from conference participants who are Veteran community members, the aim of this manuscript is to offer a Veteran community perspective on the importance of prioritizing social well-being as part of VA Whole Health programming. Through the involvement of Veterans, their caregivers and their families, the VA can offer a more culturally relevant model of holistic care that promotes social belonging, connectedness, and support for all Veterans.

Background: Up to 50% of veterans drop out of trauma-focused evidence-based psychotherapies (TF-EBP) without completing treatment or recovering; evidence suggests this is in part because their posttraumatic stress disorder (PTSD) care is insufficiently patient-centered. There is also evidence that measurement-based care (MBC) for mental health should be personalized to the patient, yet this is not common practice in VA PTSD care.

Objectives: To explore veterans' experiences and preferences for aligning measurement-based PTSD care with their own treatment goals.

Method: Qualitative interviews were conducted with veterans (n=15) with PTSD who had received at least 2 sessions of a TF-EBP.

Measures: Survey on the administration of outcomes questionnaires and demographics and an interview about their most recent TF-EBP episode.

Results: Half of veterans had symptom-focused goals and half did not; all had at least one treatment goal that was not symptom-focused. They typically met their goals about functioning and coping skills but not their symptom reduction goals. We found veterans overall were receptive to MBC but preferred patient-reported outcomes measures about functioning, wellbeing, coping skills, and understanding their trauma more than the commonly used PTSD symptom scale (the PCL-5).

Conclusions: Many veterans in this sample disliked the PCL-5 because it reinforced their maladaptive cognitions. Such veterans might be more receptive to MBC if offered patient-report outcomes measures that better align with their functional and wellbeing goals. For many goal/outcome areas, psychometrically sound measures exist and require better implementation in PTSD care. For some areas, scale development is needed.

Objective: Although recent work has highlighted high rates of suicide among American Indian and Alaska Native individuals who served in the US military, to date, a comprehensive evaluation of age-specific suicide rates, over time, has yet to be conducted.

Methods: Population-based retrospective cohort study. Average annual suicide rates (2005-2020) were computed. The cohort included 207,955 Native Veterans who were alive as of January 1, 2005, and separated from military service on or before December 31, 2020. Suicide was identified via National Death Index codes.

Results: Between 2005 and 2020, average annual, age-specific suicide rates among Native Veterans ranged from 16.32/100,000 (55+ y) to 64.49/100,000 (18-34 y). Compared with other age-related cohorts, the rate among those in the youngest age cohort (18-34y) was the highest between 2005 and 2018. The 2019-2020 average annual rate for 18- to 34-year-olds (41.86/100,000) dropped below that of the middle-aged cohort (35-45 y; 44.66/100,000). Across all age cohorts, firearms were the most used method of suicide [57.2% (18-34 and 35-54 y) to 66.17% (55+y)]; however, a notable percentage of Veterans died by suffocation, 16.54% (55 y and older), 26.71% (35-54 y), and 33.21% (18-34 y).

Conclusions: Findings highlight differences in suicide rates by age groups overtime for Native Veterans irrespective of Veterans Health Administration use and across service eras, as well as means of suicide, which also differed across groups. Increased efforts are needed to identify culturally and age-relevant intervention strategies, as well as factors associated with risk, to reduce deaths among Native Veterans.

Background: Loss of belongingness may be particularly pronounced for women veterans, representing a threat to long-term well-being. Improvements in social support through engagement in a structured peer support program may mitigate the negative effects of loss of belongingness on well-being.

Objective: We assessed the impact of participation in a peer-led, structured, social support group-based network on outcomes related to well-being [i.e., belongingness, social support, quality of life, posttraumatic stress disorder (PTSD), depression]. Subgroup analyses examined relative impact among those who completed the intervention and those reporting clinical levels of PTSD and depression symptoms.

Methods: We analyzed survey data consisting of reliable and valid measures collected at baseline, postgroup and 3-month follow-up among 393 participants in the Woven Veterans Network's (WoVeN) group program.

Results: We observed improvements in posttraumatic stress disorder (PTSD) symptoms over time. We observed additional benefits among those who received an adequate dose of the intervention (significant improvements on PTSD, belongingness) and those with clinical levels of mental health symptoms (significant improvements on PTSD, depression, belongingness, quality of life).

Conclusions: Impacts on social support may have been masked due to ceiling effects given wide dispersion baseline social support in this sample. This social support network had particularly profound impacts on well-being for those veterans who suffered from conditions for which isolation and loneliness are particularly salient.

Background: Health care systems are increasingly focused on assessing patient well-being and functioning. The objective of the current analysis was to evaluate a pragmatic question: to what extent and in what way can the PHQ-2, a routinely collected screening measure, be used to help clinicians and a learning health system understand the well-being and functioning of its beneficiaries?

Methods: The current analysis focused on 2872 Veterans who completed a large-scale longitudinal survey about health and wellness for whom we were able to link survey responses to PHQ-2 scores recorded in their electronic health records (EHR). Regression analyses examined the cross-sectional and longitudinal associations between PHQ-2 scores recorded in the EHR and measures of well-being (life satisfaction, purpose in life, and social health) and functioning (pain severity and interference, physical and mental health, and perceived stress).

Results: Veterans were aged 65 years on average (11% women). PHQ-2 scores were correlated cross-sectionally with all well-being and functioning measures; however, there was minimal variance accounted for. Changes in the PHQ-2 over time were associated with 3 measures: purpose in life (b = -0.19; 95% CI: -0.34, -0.04), mental health functioning (b = -0.29, 95% CI: -0.54, -0.04), and perceived stress (b = 0.13; 95% CI: 0.02, 0.24).

Conclusions: The PHQ-2 was minimally associated with patient well-being and functioning, with more work needed on how the PHQ-2 may be used in large health care settings within the context of VA Whole Health. Assessment of well-being is critical as VA's Whole Health transformation continues, and identifying strategies for well-being measurement is an integral next step.

Background: Interventions based on the Veterans Health Administration's (VHA) Whole Health (WH) initiative may be beneficial for veterans with Gulf War Illness (GWI) through specific, measurable, action-oriented, realistic, and timed (SMART) goal setting and monitoring of perceived goal attainment with the Personal Health Inventory (PHI).

Objectives: This secondary analysis of 2 randomized controlled trials focused on (1) categorizing SMART goals set during a wellness intervention based on the VHA's WH approach to identify goals most relevant for veterans with GWI and chronic pain and (2) descriptively examining the PHI over a course of treatment to assess its preliminary sensitivity to change. Also, changes in PHI for those who engaged in the intervention in-person versus remotely were compared.

Subjects: Participants were 49 veterans with GWI and chronic pain who received a 12-week, 24-session group wellness intervention delivered in-person or remotely due to the COVID-19 pandemic.

Results: SMART goal themes mapped onto the 8 areas of self-care presented in the WH program's circle of health with high categorical adherence. Most participants set goals in categories for working the body, food and drink, and personal development. The wellness intervention was related to improvements in perceived goal attainment as measured by the PHI in both in-person and remote participants, which indicates that the PHI may be sensitive to change over time.

Conclusions: These preliminary findings set the stage for future research on wellness interventions for veterans with GWI and chronic pain and the measurement of whole-person outcomes.