Medical Care最新文献

Introduction: Burn pit smoke exposure (BPSE) during military deployment has been linked to long-term cardiorespiratory conditions, but its relationship with sleep apnea (SA) remains unclear. This study examines the association between BPSE and SA using Veterans Health Administration (VHA) electronic medical records (EMR) and the Airborne Hazards and Open Burn Pit Registry (AHOBPR).

Methods: We conducted a retrospective cohort study of veterans from AHOBPR with VHA sleep study data. BPSE was classified into quartiles based on the duration of exposure, and SA severity was measured using the Apnea-Hypopnea Index (AHI). Logistic regression models and Cox proportional hazards models were used to evaluate the association between BPSE and SA, adjusting for confounders such as age, body mass index, smoking status, post-traumatic stress disorder (PTSD), and comorbid disease burden.

Results: The study included 17,064 veterans (mean age 40.2 y; 89.6% male; 58.3% with PTSD). Veterans in the highest BPSE quartile (≥245 d) had an unadjusted OR of 1.13 for SA, which became nonsignificant after adjustment (aOR: 1.10, P=0.058). The median time to SA diagnosis was 8.8 years in the highest BPSE group versus 11.1 years in the lowest. The adjusted Hazard Ratio for earlier SA diagnosis in the highest BPSE quartile was 1.16 (95% CI: 1.10, 1.22).

Discussion: Although BPSE was not associated with SA prevalence, it was linked to earlier diagnosis. BPSE-related airway inflammation or increased health care use among exposed veterans may explain this pattern. Findings support early surveillance and screening for SA in highly exposed veterans.

Background: First-year registered nurses (RNs) have the highest turnover rate of all hospital-based RNs, and often face various challenges during their transition to practice. RN transition-to-practice programs (RNTTPs) can potentially alleviate critical RN staffing shortages and support the development of the nursing workforce's future.

Objectives: To (1) capture and critically appraise the landscape of existing synthesis efforts on RNTTPs and (2) synthesize included reviews' findings to assess the potential benefits of RNTTPs for organizational, nursing, and patient outcomes and descriptions of RNTTPs.

Research design: We conducted a systematic review of reviews to identify published evidence syntheses evaluating RNTTPs for newly graduated RNs.

Results: Nineteen evidence reviews were included. Despite having similar scopes, there was little overlap in their included literature, and no single review included the majority of identified original research studies. Two reviews with high methodological rigor and high topical relevance emphasized the methodological issues in the available evidence, which used a mix of methodological approaches, and indicated a connection between RNTTPs and increased critical thinking, competency, and retention. Published reviews suggest program lengths between 6 and 12 months, but evidence for optimal program length was inconclusive or unsupported.

Conclusions: RNTTPs that have been piloted and implemented in recent years deserve more rigorous evaluation to answer critical questions about their role in organizational, nurse, and patient outcomes. However, before best practices can be ascertained to support scaling and sustainment, their potential benefits must first be verified.

Background: Environmental exposures are common, may impact health, and may cause concerns. There have been calls to improve clinical care for exposure concerns through an "informed care" approach, which designs care in consideration of the patient's experiences with the concern. Understanding Veterans' experiences and concerns about military environmental exposures through an "informed care" approach may help with care; however, there is a need to better define the core components of this model of care.

Objectives: The current project aimed to define the core components of "exposure-informed care" using a modified Delphi quality improvement study.

Research design: Delphi methodology utilizes expert opinion in a series of rounds and is appropriate to use when there is incomplete knowledge, uncertainty, or lack of evidence on a specific topic.

Results: Experts in military environmental exposures (n=35) provided their feedback on the definition of "exposure-informed care." After 4 rounds of rating, 20 statements were agreed upon as core components of exposure-informed care. Accepted statements about the core components of exposure-informed care were coded into a 6-part framework: (1) use concordant communication, (2) build trust, (3) provide resources and support, (4) assess and document, (5) take professional responsibility, and (6) integrate into care.

Conclusions: The 6-part exposure-informed care framework represents experts' definition of the core components of "exposure-informed care." Future implementation of exposure-informed care and the impact of each theme are discussed.

Background: Health care delivery organizations increasingly employ advanced practice professionals (APPs) and participate in alternative payment models such as accountable care organizations (ACOs). Given the former's incentive to constrain spending, APPs' practice patterns may vary in ACO-participating versus non-ACO practices.

Objectives: To compare outpatient care provided by APPs and physicians through ACO participation.

Research design: We used multivariate linear regression to compare measures of workload allocation and billing across ACO-participating and non-ACO practices in 2022, controlling for practice size and market.

Subjects: A total of 91,149 practices, 12,072 in a Medicare Shared Savings Program ACO in 2022.

Measures: We used 100% fee-for-service Medicare claims to identify ACO-participating and non-ACO practices. For every practice, we calculated the share of outpatient encounters provided by APPs rather than physicians and the share of APP-provided encounters billed indirectly to Medicare. We also calculated the share of annual wellness visits, chronic condition care management services, transitional care management services, and postoperative visits provided by APPs.

Results: APPs provided a smaller share of outpatient encounters at ACO-participating versus non-ACO practices, but were more likely to bill indirectly. Among most categories of routine services (eg, annual wellness visits and chronic condition management), APPs provided a smaller share of services at ACO-participating versus non-ACO practices. In the largest quartile of practices, APP practice patterns were more similar across ACO-participation status, and indirect billing was less likely within ACOs.

Conclusions: Findings provide little evidence that ACOs deploy their APP workforce in a more cost-conscious manner than non-ACOs.

Background: Few health care organizations have structured approaches to assimilate and analyze disruptive behavior data. In 2012, Veterans Affairs (VA) developed the Workplace Behavior Risk Assessment (WBRA), a tool that collects behavioral threat data from multiple systems, consolidates it, and tailors staff training based on the frequency and type of events.

Objective: This paper provides an overview of the WBRA and how it can inform nurse training.

Methods: A repeated measures design evaluated trends in workplace violence reporting and event rates across 140 VA health care systems from 2013 to 2024. Data were collected annually using a standardized electronic reporting system and reviewed by multidisciplinary teams. Risk levels were categorized based on the frequency and type of disruptive events, including manual restraint and physical or verbal violence. Descriptive statistics were used to prevalence of incidents and analyze trends, particularly among nursing professionals in high-risk areas.

Results: Four VA workplace settings: acute care (psychiatric and medical/surgical), emergency/urgent care, and Community Living Centers (CLC) were consistently classified as high-risk. In FY 2024, nursing staff accounted for over 90% of reports in inpatient and extended care settings and 73% in emergency/urgent care. From FY 2013 to FY 2024, reports involving nurses increased significantly, with the largest rises in CLCs (289%) and Medical/Surgical Units (271%), whereas the proportion of physical violence reports involving nurses rose from 59% to 83%.

Conclusions: The WBRA enables health care systems to analyze behavioral risk data to align training with risk.

Background: Gulf War illness is a chronic multisymptom illness impacting Veterans of the 1990-1991 Persian Gulf War. Toxic exposures are believed to be associated with the condition, but little is known about how multiple types of exposures can impact the disease. The aim of this study is to determine if a positive association exists between the multiplicity of exposure types and symptom severity score.

Methods: A cross-sectional survey design was used in which Persian Gulf Veterans completed a questionnaire with items related to symptom severity and types of self-reported toxic exposures. Linear regression models were used to examine the association between the number of types of toxic exposures and symptom severity scores. We also examined the association between each type of reported exposure and symptom severity score.

Results: Veterans with a greater number of self-reported toxic exposures reported higher scores on symptom severity. While no individual exposure type reached a statistically significant association with symptom score, radiation and biological agent exposures showed the strongest association.

Discussion: We found a positive association between the number of toxic exposure types and total symptom severity. Veterans who self-reported having Gulf War Illness also reported more types of toxic exposures compared with Veterans who did not report having Gulf War Illness. Radiation and biological agent exposure showed the strongest positive association with symptom scores, yet very few Veterans reported isolated exposure of these types. Our findings suggest that cumulative exposure to multiple types of toxins could be associated with the development and severity of Gulf War Illness symptoms.

Background: Prior literature has shown that favorable selection of enrollees in Medicare Advantage (MA) that is not accounted for under the Hierarchical Condition Category (HCC) risk adjustment model can result in significant overpayments to MA plans. Detailed data from the Veterans Health Administration's (VHA) Nosos risk score can measure previously undetected favorable selection in a unique cohort of patients.

Objective: To analyze characteristics associated with Veteran enrollment in MA versus Traditional Medicare (TM) and quantify previously undetected favorable selection.

Research design: Pooled, cross-sectional study using nationally representative VHA survey data and VHA administrative data, 2016-2019.

Subjects: Dual VHA-Medicare enrollees.

Measures: Enrollee characteristics, risk scores, and VHA inpatient and outpatient costs.

Results: Compared with VHA-TM enrollees, VHA-MA enrollees were older [73.8 (8.5) vs. 72.2 (8.2) y; SMD=0.19], more likely to have Medicaid coverage (13.7% vs. 4.7%; SMD=0.31), less likely to use VHA care (67.4% vs. 74.3%; SMD=0.26), and more likely to be in the lowest priority group (facing VHA copays) (21.4% vs. 17.6%; SMD=0.15). However, in 2019, MA enrollees had Nosos scores that were 25.6 percentage points lower (95% CI: -35.7, -15.5) than TM enrollees, signaling a healthier population. In adjusted comparisons, MA enrollees had $453.79 lower VHA costs (95% CI: $832.30, $75.27) than TM enrollees.

Conclusions: MA plans enroll Veterans who are healthier and less costly than TM-enrolled Veterans. Our findings underscore plans' potential selection of enrollees based on characteristics unobservable in the HCC risk adjustment model. Policymakers may consider opportunities to adopt additional risk-adjustment factors specifically for dual VHA-MA enrollees.