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Research News

HSR&D to receive extra $4,000,000 over the next two years!

July 2, 2014 (updated)

Due to a recent multi-million dollar settlement, HSR&D will receive a total of four million dollars ($4,000,000) over the next two years to support research on Service Quality Improvement ($1,250,000), Mental Health ($1,250,000), Homelessness ($750,000) and Women's Health Initiatives ($750,000). See press release for details of the settlement.

Projects Selected for Funding with Special Use NYAG Funds

November 24, 2014

A multi-million dollar settlement was reached by the New York Attorney General after an investigation into direct mail fundraising abuses at one of the country's largest Veterans' charities. This settlement is to be used on behalf of disabled Veterans, specifically to advance the science in the areas of mental healthcare for Veterans, Veteran homelessness, improving the quality of Veteran healthcare, and healthcare for women Veterans. The following peer reviewed HSR&D projects were selected for funding to help fulfill this goal.

Improving the Quality of Veteran Healthcare

Optimizing the Value of Primary Care Delivered by Nurse Practitioners

Nurse practitioners (NPs) are an essential element of primary care delivered in the VA and elsewhere, but some questions remain about whether care delivery to more clinically complex patients in the VA healthcare system varies between NPs and physicians. This project will use data from VA's national electronic health record, along with the VA's new health risk scoring system, to identify Veterans at different levels of health risk and to examine care provided by nurse practitioners and physicians. This project also will examine health outcomes and patient satisfaction. Specific project goals include:

  • Compare healthcare use and costs between VA patients cared for by nurse practitioners and medical doctors across a range of health risk;
  • Compare clinical outcomes and patient satisfaction between Veterans cared for by NPs and MDs across a range of health risks; and
  • Assess patient experience and feasibility and acceptability of the structured patient assignment using qualitative interviews.

Principal Investigator: Chuan-Fen Liu, Ph.D.
HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA
VA Puget Sound Healthcare System
Seattle, WA

Improving Surgical Quality: Risks and Impact of Readmission

Hospital readmissions have recently been targeted as a hospital quality measure. Readmissions can increase both healthcare costs and resource use and are associated with poorer patient outcomes. While much research on readmissions has been done in the medical patient population, there has been little study of reasons for readmission in the surgical patient population. In contrast to medical admissions, index surgical admissions are usually planned, and post-hospital care coordination often begins before the patient is admitted to the hospital. It is important to identify which patients have high risk for readmission after surgery - and to understand whether a readmission is potentially preventable, represents a quality of care issue, or indicates failure of the care transition plan. Specific project goals include:

  • Evaluate the contribution of patient, procedure, post-operative complication, and system factors on readmission within 30 days of hospital discharge following surgery, and use these data to:
  • Develop and validate a readmission risk prediction tool that can be used real-time,
  • Develop a classification of readmission reasons, and
  • Explore processes of care linked with readmission.
  • Assess potential patient factors not currently collected by VA's Surgical Quality Improvement Program at discharge and determine their association with readmission.
  • Rank reasons for readmission categories developed from Aims 1 and 2 as potentially preventable, and appropriateness as a measure of surgical quality.

Principal Investigator: Mary Hawn, M.D.
Birmingham VA Medical Center
Birmingham, AL

Mental Health Care for Veterans

Veteran Peer-Assisted Computerized Cognitive Behavioral Therapy for Depression

Evidence-based psychotherapies are effective treatments for depression. However, engaging and retaining patients in evidence-based psychotherapies for depression is challenging. Initiation and engagement in depression therapy may be increased if patients are offered timely access to a highly flexible, evidence-based treatment options, such as a tailored, web-based computerized cognitive-behavioral therapy (cCBT) program. While cCBT can be an effective treatment, it has much larger effects when it is supported by clinicians or other trusted individuals.

VA peer specialists, a rapidly increasing workforce in VA mental health, are ideal candidates to support patients' engagement in depression treatment and in cCBT. Peer specialist support for cCBT may enhance completion of the program and overall effectiveness through regular "check ins," and through providing peer-specific experiences, such as sharing of lived experiences and modeling of self-management and recovery. Investigators in this project will conduct a randomized controlled trial of Peer-Supported (PS) cCBT versus enhanced usual care (EUC) for 330 Veterans with new episodes of depression in primary care at three VA sites and their associated Community-Based Outpatient Clinics (CBOCs). Specific aims include:

  • Comparing PS-cCBT versus EUC on:
    • Patient symptomatic, functional, and recovery-oriented outcomes;
    • Depression coping skills, antidepressant medication adherence; and
    • o Initiation and completion of more intensive traditional psychotherapy.

This project addresses two important VA initiatives - providing evidence-based care for VA patients with depression and providing recovery-oriented services using peer specialists. The proposed intervention may increase patient engagement in depression care and provide an important evidence-based role for current and incoming VA peer specialists.

Principal Investigator: Marcia Valenstein, M.D.
HSR&D's Center for Clinical Management Research (CCMR)
VA Ann Arbor Healthcare System
Ann Arbor, MI

Metabolic Effects of Medications for Serious Mental Illness in Female Veterans

Individuals with serious mental illness (SMI) experience higher rates of morbidity and premature mortality than the general population, which has been attributed, in part, to their increased prevalence of obesity and cardiovascular disease. Weight gain and other metabolic side effects of antipsychotic medications (APMs) and mood stabilizer medications (MSMs) have been implicated in the high rates of these disorders, of which women with SMI are disproportionately affected - and which may be impacted by other effects of specific concern to women. In preliminary work using VA data, researchers observed that female Veterans with SMI were more likely to be prescribed APMs and MSMs with a lower risk of weight gain/metabolic side effects than men. These data, however, could not elucidate the relative influence of patients versus prescribers on the observed prescribing patterns and the unique perspective each brings to shared treatment decision-making. Further, while these findings suggest women Veterans are possibly being subjected to fewer physical health risks from APM/ MSMs, the actual impact of these treatment decisions on both the physical and mental health of female Veterans is unknown. The objectives of this pilot study are to understand female Veterans' and VA mental health prescribers':

  • Knowledge, attitudes, and experiences with weight gain and other metabolic side-effects of APMs/MSMs, and their perceptions of how those factors influence medication decision-making;
  • How side-effects of APMs/MSMs that are specific to women (e.g., menstrual abnormalities, reproductive and sexual dysfunction, potential teratogenicity) influence medication decision-making relative to weight gain/metabolic side effects; and
  • Experiences of the effects of APM/MSM treatment choices on adherence to treatment and the physical and mental health of women.

Principal Investigator: Julie A. Kreyenbuhl, Pharm.D., Ph.D.
Baltimore VA Medical Center
Baltimore, MD

Veteran Homelessness

Identifying and Measuring Risk for Homelessness among Veterans

To prevent and end homelessness among Veterans, VA has refined its programming and policies to focus on ending chronic homelessness and preventing new episodes of homelessness. To support the latter, VA has allocated close to $1 billion toward homelessness prevention services since FY2011 through the Supportive Services for Veteran Families (SSVF) program. To assist in the identification of Veterans in need of homelessness prevention, the National Center on Homelessness among Veterans developed the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability among Veterans who present for outpatient care and are not already engaged with VA Homeless Programs. During FY2013, more than 4 million Veterans responded to the HSCR. Among those screened, 0.8% reported current homelessness and 1.0% reported imminent risk. This study will evaluate VA's efforts at identifying Veterans at risk of homelessness and linking them with services of their choosing that are both efficient and effective. Specific project goals include:

  • Validate the HSCR and assess prevalence and risk factors for homelessness and imminent risk among Veteran users of VHA healthcare services;
  • Assess the effectiveness of the HSCR at linking Veterans who screen positive for homelessness or risk with subsequent services; and
  • Evaluate the psychometric properties and efficacy of an existing instrument used by the SSVF program to quantify risk of homelessness among Veterans.

Principal Investigator: Ann Elizabeth Montgomery, Ph.D., M.S.W., M.P.A.
VA's National Center on Homelessness among Veterans
HSR&D Center for Health Equity Research & Promotion (CHERP)
Philadelphia VA Medical Center
Philadelphia, PA

Healthcare for Women Veterans

Impact of Sexual Assault and Combat-Related Trauma on Fertility in Veterans

VA recently renewed efforts to provide limited infertility care to Veterans, partly in response to a Senate bill from December 2012. Very little is known about the true prevalence of infertility in Veterans, especially in the male population, or the impact of combat-related and sexual assault trauma on fertility, much less the existing disparities, barriers, and preferences regarding infertility care in the VA system. The Pentagon is monitoring the number of OEF/OIF/OND Veterans who have suffered pelvic or genital injuries that could impact reproductive capability, and traumatic injury benefits are now being paid to those affected. Sexual assault is an even more common trauma in female Veterans and a relatively overlooked issue for male Veterans; officials estimate that 26,000 military members were sexually assaulted in 2012 alone (up 35% from the previous year). This research team's study of 1,004 female Veterans suggested sexual assault is also a risk factor for infertility as well as for delay and avoidance of pregnancy. Other studies indicate duration of deployment, concurrent mental health diagnoses, and traumatic brain injury can also increase the risk of infertility in Veterans. Specific project goals include:

  • Assess infertility prevalence in a nationally representative sample of reproductive-aged male and female OEF/OIF/OND Veterans.
  • Compare prevalence of infertility in those who have and have not experienced sexual and/or combat-related trauma - and investigate how physical and psychological injury, and biological and behavioral changes mediate risk of infertility due to these traumas.
  • Identify unexpected connections between trauma exposures and infertility, and explore Veteran-identified best opportunities for VA intervention(s).

Principal Investigator: Ginny Ryan, M.D.
Iowa City VA Medical Center
Iowa City, IA

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