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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.

Background: Tennessee ranks sixth in stroke mortality in the United States. Yet the patterns of stroke mortality vary significantly across counties and over time.

Objectives: This study aims to examine spatiotemporal disparities of stroke mortality at the county level in Tennessee from 1969 to 2020.

Research design: A population-based study using the national vital statistics system of stroke mortality data through the Surveillance, Epidemiology, and End Results and National Center for Health Statistics (SEER-NCHS) database.

Subjects: Patients older than 35 years who died from stroke in Tennessee from 1969 to 2020.

Methods: Data from the SEER-NCHS were aggregated into 4 periods (1969-1980, 1981-1992, 1993-2004, and 2005-2020), and age-adjusted stroke mortality rates were calculated by county and by race and sex for each time period.

Results: The stroke mortality rates in Tennessee declined by 35.6%, 28.3%, 7.1%, and 24.4% in 1969-1980, 1981-1992, 1993-2004, 2005-2020, respectively. The degree of decline varied by race and sex groups. In the first 2 periods, the largest decline in stroke mortality was observed among Black women (43.2% and 31.5%). During 1993-2004, the largest decline was observed among Black men (22.4%), while the largest decline was observed among white women during 2005-2020 at 25.5%. There were urban-rural disparities in stroke mortality across counties and over the 4 periods. In general, urban and rural mortality rates were similar from 1969 to 1992; however, a substantial decline (24.1%) was observed in urban counties during 1993-2004, while a larger decline (34.6%) occurred later in rural counties during 2005-2020. County-level variations in stroke mortality were also evident across the 4 periods.

Conclusion: Substantial disparities in stroke mortality by counties and race-sex subgroups persisted over the past 5 decades. The disease burden was clustered in a few counties and disproportionately higher among vulnerable populations.

Objective: To examine the long-term impact of Medicaid expansion on not-for-profit (NFP) hospital community benefit (CB) spending among hospitals located in Arkansas and Kentucky (9 y postexpansion), Louisiana (7 y postexpansion), and Alabama, Mississippi, Tennessee, and Texas (nonexpansion states).

Background: To maintain tax-exemption status, NFP hospitals must provide CB, such as charity care and population health initiatives. In the short term, Medicaid expansion has led to decreased charity care and increased Medicaid shortfalls, but no change to other CB categories. Given these early findings and Medicaid expansion's impact on hospital finances, it is important to understand whether hospitals continued to adjust their CB spending.

Methods: We used data on hospital CB spending (2011-2022), for NFP hospitals located in the West South Central and East South Central Census divisions. States that expanded Medicaid formed the treatment group (69 hospitals) and nonexpansion formed the control group (90 hospitals). We used staggered difference-in-differences and event study designs to examine changes in total CB, clinical, and population health spending as a share of operating expenses.

Results: We found that Medicaid expansion was associated with a decrease in total CB spending by ∼$782,000 per hospital (P=0.01). Clinical and population health spending decreased by ∼$759,000 (P=0.01) and $92,000 per hospital (P=0.009), respectively.

Conclusion: Among southern hospitals, Medicaid expansion led to sustained long-term reductions in CB spending. Our findings suggest that states may need to implement CB laws to encourage hospitals to invest more in their communities.

Objective: To assess the relationship between burnout scores for patient safety professionals and perceived support from the National Center for Patient Safety (NCPS) and direct communication with medical center directors in the Veterans Health Administration (VA). Our secondary objective was to analyze qualitative responses on communication barriers to identify areas for improvement.

Study setting and design: A system-wide cross-sectional quality improvement survey of VA patient safety professionals.

Data sources and analytic sample: Our final sample included 212 patient safety professionals who completed a questionnaire adapted from the Copenhagen Burnout Inventory. The survey measured personal, work-related, and facility-related burnout, with an additional item addressing the emotional impact of patient safety events. Nonparametric tests were used to examine relationships due to small sample sizes and non-normal distributions.

Principal findings: Feeling supported by the NCPS was associated with significantly lower burnout scores across all dimensions ( P <0.001). Facility staff-related burnout was higher among those reporting communication barriers with directors ( P =0.012), although one-on-one communication was not significantly associated with lower burnout scores. Qualitative responses from 12 participants identified logistical and bureaucratic challenges as key barriers to direct communication with directors.

Conclusions: These findings indicate that organizational support may help mitigate burnout among patient safety professionals. Addressing logistical and bureaucratic barriers could enhance communication and improve the effectiveness of patient safety programs in the VA as well as other systems of care.