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Background: US service members are often exposed to a range of service-related hazards. To date, there has been limited synthesis of the existing research conducted on military environmental exposures and subsequent psychiatric conditions and symptoms.

Objective: To systematically review and characterize the main features of studies examining associations between military exposures and mental health outcomes.

Methods: We used evidence mapping methodology to systematically search MEDLINE, Embase, PsycINFO, and PTSDpubs for studies of toxic exposure during military service and psychiatric outcomes, which included psychiatric diagnoses, psychiatric symptoms, and neurocognitive functioning.

Results: We identified 49 studies; most were comprised of predominantly White, male veteran samples. Chemical exposures, including chemical munitions from the Gulf War era and Agent Orange from the Vietnam War era, were the most frequently examined military toxic exposures. Symptoms of depression, PTSD, and anxiety were the most commonly examined psychiatric outcomes. Only 9 studies assessed neurocognitive functioning. We found extensive variation in how exposures and outcomes were defined and measured. Most exposure and symptom data were based on self-reports. Overall, available evidence suggests that veterans reporting environmental toxic exposures may report relatively high levels of mental health needs.

Conclusions: We found broad evidence that toxic exposure was associated with poorer mental health outcomes, though the ability to draw stronger conclusions is limited by the quality of the current literature. Future research should focus on longitudinal studies of toxic exposure and mental health that include more broadly representative military populations, including diverse samples and more recent service cohorts.

Background: The COVID-19 pandemic resulted in extended disruption to the health care system. National-level data-driven comparisons of inpatient nurse staffing and workload before and during the pandemic have been limited.

Objectives: Assess the extent to which registered nurse (RN) staffing and workload changed from prepandemic levels in a national integrated health care system.

Research design: Longitudinal descriptive analysis. Medication pass analysis using bar code medication administration data for the peak-time medication pass (PTM) assessing year-over-year changes from 2019 to 2022. To assess significance of year-over-year changes in means we used the Welch 2-sample t test.

Subjects: Staff (N=42,999) administering PTM medications on Veterans Health Administration acute-care inpatient units (643 units; 127 facilities) from January 1, 2019, to December 31, 2022 (3,681,802 staff days).

Measures: Staffing: unique staff, staff days, staff per day, patients per staff (PPS); workload: patient days, medications, medications per patient, medications per RN, PTM duration.

Results: RNs administered 93.6% of peak-time medications. Fewer non-RNs administered medications after the onset of the pandemic. The average number of patients per RN (PPS) in 2022 was 3.3 on medical, 3.2 on mixed medical-surgical, 3.3 on surgical, 2.5 on step down, and 1.5 on critical care units. The greatest increase in PPS from 2019 to 2022 occurred on surgical units (+0.20, P<0.0001). Across nearly all unit types and levels of PPS, medications per RN were greater and duration was longer in 2022 than in 2019.

Conclusions: RN staffing and workload fluctuated widely at the onset of the pandemic. In 2022, new patterns began to emerge, showing a higher RN workload than before the pandemic.

Objective: We sought to identify key areas to inform the development of Veteran-facing airborne hazard exposure communication materials.

Background: Military personnel are commonly exposed to environmental and occupational hazards. Airborne hazard exposures may be particularly salient to Veterans because they are common, and the relationship to health concerns is often uncertain. VA offers a toolkit to help providers navigate caring for Veterans with airborne hazard exposure concerns. Veteran-facing materials, which address their concerns, are lacking.

Methods: Five generative, qualitative focus groups with Veterans with airborne hazard exposure concerns. Focus group discussions covered information needs, how the VA should communicate about environmental exposures when the evidence is unclear, communication preferences, and how they get health information.

Results: We identified 3 areas important to communicating with Veterans about their airborne hazard exposure concerns. (1) Veterans want personalized, transparent and comprehensive communication. (2) Veterans want to be able to act on the information with tangible next steps. (3) Diverse, multimodal communication strategies are needed to reach the range of Veterans with concerns about airborne hazard exposures.

Conclusions: In situations of uncertainty, where robust clinical guidance is limited, Veterans want Veteran-centered, transparent, respectful communication that attends to their socially and historically rooted exposure experiences. The information they receive on airborne exposures should be actionable and delivered through a variety of modalities.

Background: Veteran participants in the Airborne Hazards and Open Burn Pit Registry (AHOBPR) report respiratory and sleep-related symptoms, including sleep-disordered breathing and difficulty sleeping. The AHOBPR Questionnaire elicits sleep-related disturbances and other health outcomes potentially associated with burn pit exposures. Responses to this questionnaire may influence resource allocation and future longitudinal studies of toxic sequelae. The level of agreement between sleep apnea and insomnia responses to the AHOPBPR questionnaire and clinical diagnoses of sleep apnea and insomnia in the electronic medical record (EMR) is unclear.

Objective: In this study, we compare concordance between reports of symptoms associated with sleep apnea and insomnia to corresponding clinical diagnoses documented in EMRs among Veterans in the AHOBPR.

Methods: We included 469,179 Veterans with AHOBPR survey responses and available EMR data in the Veteran Health Administration. Concordances between reports of sleep-related symptoms on the AHOBPR questionnaire and relevant EMR diagnoses were analyzed for 469,179 Veterans. Concordance was assessed with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa coefficients. We further considered sex differences in concordance measures.

Results: Reports of symptoms associated with sleep apnea were common (52% overall, 54.5% in men, 28.5% in women) as were EMR diagnoses (31.6% overall, 32.8% in men, 19.8% in women). The overall concordance between self-reported and EMR diagnoses for sleep apnea was fair (kappa=0.38). Reports of symptoms associated with insomnia were highly prevalent (81% overall, 80.8% in men, 82.6% in women) but poorly aligned with EMR diagnoses (17.8% overall, kappa=0.08). Agreement between reports of symptoms associated with sleep apnea and EMR-diagnosed sleep apnea was higher for females (kappa=0.46) than for males (kappa=0.37).

Conclusion: This study highlights significant discrepancies between self-reported symptoms and EMR diagnoses of sleep apnea and insomnia among Veterans who completed the AHOBPR survey. While fair agreement for sleep apnea suggests some alignment with clinical diagnosis, poor concordance for insomnia highlights the limitations of self-reported case identification methods.

Background: There is an acknowledged need to improve care for patients with persistent physical symptoms. Veterans who served in the 1990-91 Gulf War are a subpopulation of U.S. military Veterans who have been struggling with persistent physical symptoms for decades. The current study sought to characterize Veterans' historic path through the health care system and current experience of care to identify opportunities to improve care.

Methods: Analysis of interviews conducted with 31 Veterans who met criteria for Gulf War Illness (GWI) was conducted to understand Veterans' health care journeys, from symptom onset to the present.

Results: Early in their journey, Veterans felt uncertain about the nature of their condition and how to explain it to clinicians. Veterans described a cycle of referrals to specialists to pursue individual symptoms and subsequent return to primary care with few actionable findings. During this cycle, Veterans often felt dismissed or invalidated by clinicians. Over time, most Veterans felt care became increasingly fragmented, with multiple clinicians caring for them without a plan to manage GWI and little acknowledgement of GWI as a discrete illness. Further in their journey, some Veterans were referred to tertiary centers where they encountered a more holistic approach.

Conclusions: Findings point to the need to shift care for Veterans with GWI, and similar conditions, away from overly focusing on individual symptoms. Instead, primary care clinicians need training and support, potentially from tertiary care experts, to develop and implement holistic care plans that recognize GWI as a complex chronic condition.

Background: The rising demand for health care delivery and an aging workforce is of particular concern in rural areas, where health care access depends upon an adequate nursing workforce. To address this shortage and optimize care, it is essential to measure when registered nurses (RN) leave inpatient direct care positions (ie, inpatient RN turnover) and identify modifiable factors correlated with RN turnover.

Objectives: Apply a novel method for characterizing inpatient RN turnover to understand factors associated with variation in RNs leaving inpatient positions at rural and urban Veterans Health Administration (VHA) hospitals.

Project design: Retrospective cohort study.

Subjects: Direct care RNs working on VHA regular acute care units for at least 15 days across a 60-day period during fiscal year 2022. Measures: outcome: electronic health record (EHR)-derived RN turnover on inpatient medical, surgical, or mixed medical-surgical units; exposure: rurality of hospital location.

Results: Among the cohort of 10,415 inpatient RNs in FY22, 3537 RNs left inpatient direct care in FY22 (34.0%). There were 127 inpatient RN turnover events in rural VHA hospitals (42.8% of 297), compared with 3410 in urban (33.7% of 10,118) (P<0.001). However, in the final mixed-effects logistic regression model, individual RN-specific features and care delivery structure, not rurality (P=0.843), were more strongly associated with variation in turnover events.

Conclusions: Inpatient RN turnover was greater in rural versus urban hospitals, but rurality alone was not associated with turnover after multilevel adjustment.

Background: Multiple studies have linked higher levels of BSN-prepared nurses to lower odds of postsurgical mortality and failure-to-rescue (FTR; ie, death following the development of a postsurgical complication).

Objective: The purpose of this national evaluation was 2-fold: (1) to assess the proportion of direct care nurses holding a BSN or higher degree in VA Medical Centers; and (2) to examine the association between the proportion of BSN-prepared nurses in VA Medical Centers and the outcomes of hospitalized Veterans undergoing commonly performed surgical procedures.

Results: Across our sample of 117 VA Medical Centers nationally, the mean percentage of RNs with a BSN degree or higher in nursing was 55% (SD=16%) and ranged from 9% to 84%. Every 10-point increase in the percentage of nurses with a BSN degree or higher was associated with a 9% decrease in the odds of 30-day mortality and an 8% decrease in the odds of FTR among a cohort of Veterans undergoing commonly performed general, orthopedic, and vascular surgeries.

Conclusion: Higher proportions of nurses with a BSN or higher in VA Medical Centers is associated with lower postsurgical mortality and FTR among Veterans receiving surgery. These findings confirm within the VA what has been shown in non-VA hospital settings for the last 20 years. Ongoing monitoring and improvements, which are both considered foundational to the tenets of learning health systems and high-reliability organizations, are needed to support staffing with higher proportions of frontline BSN-prepared nurses in VA Medical Centers.

Objectives: This paper examines whether Medicaid payment rates are aligned with the cost of caring for Medicaid residents and how this relationship varies by facility characteristics.

Background: Medicaid is the primary payer for most nursing home residents, but limited information exists on the relationship between payment rates and costs of caring for Medicaid beneficiaries.

Methods: Per diem Medicaid payment rates were obtained directly from states. Estimated Medicaid per diem costs were calculated from Medicare Cost Reports, then combined with payment rates to calculate a payment-to-cost ratio. Medicaid payment rates and payment-to-cost ratios were examined by key facility characteristics: ownership, Medicaid payer-mix, and nursing staff levels.

Results: Nationally, the mean Medicaid payment rate was $198 per resident-day, while the mean Medicaid cost was $253. On average, Medicaid payment rates covered about 82 cents per dollar of estimated Medicaid costs in nursing homes in 2019. This figure declined to 76 cents in not-for-profit facilities. Most nursing homes (92%) had Medicaid per-diem costs that exceed Medicaid payments. Nursing homes with a greater share of Medicaid residents had Medicaid costs that better aligned with Medicaid payment rates. Furthermore, Medicaid payments covered a smaller share of Medicaid costs in nursing homes with the highest nursing staff levels compared with those with lower staffing levels.

Conclusions: Policymakers should consider Medicaid payment as part of nursing home reform, as Medicaid payment levels that do not cover costs reduce available financial resources to increase nursing staff levels and improve quality of care absent cross-subsidization from other funding sources.

Background: Between 1953 and 1987, the groundwater at Marine Base Camp Lejeune in North Carolina was contaminated with chlorinated solvents. Legislation enacted by the federal government aimed to provide disability compensation and access to health care to Veterans for conditions related to these exposures.

Objective: We assessed the impact of the Camp Lejeune-related legislation on Veterans' experiences with health care access and disability claims.

Measure: A total of 8864 Veterans who were at Camp Lejeune between 1975 and 1985 were invited to complete an online survey about their experiences with health care and seeking compensation for conditions associated with toxicant exposure.

Results: Approximately 964 surveys (13%) were fully completed and analyzed. One-third of respondents reported a diagnosis of at least one associated or presumptive condition linked to toxicant exposure. Veterans who reported living/working in higher risk areas at the Camp had a 2.02 [CI: 1.41, 2.90] greater odds of being diagnosed with one of these conditions, controlling for demographic characteristics. While most Veterans accessed and were satisfied with Veterans Health Administration (VA) care, those who applied for disability compensation found the process to be unhelpful.

Conclusion: Conditions associated with or presumptive for toxicant exposures at Camp Lejeune were frequently identified by respondents. Veterans who lived/worked in a high-risk area of the camp were twice as likely to have any of these conditions. There is a need for additional education of Veterans regarding the Camp Lejeune legislation, particularly around the disability claims filing process, and the increased risk of those who lived near the contaminated wells at Camp Lejeune.