Publications

INTRODUCTION

The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program.

METHODS

The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011-October 2014 and November 2015-December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre-post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019.

RESULTS

Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre-post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits.

CONCLUSIONS

Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.

BACKGROUND

The opioid use disorder (OUD) epidemic is a national public health crisis. Access to effective treatment with buprenorphine is limited, in part because few physicians are trained to prescribe it. Little is known about how post-graduate trainees learn to prescribe buprenorphine or how to optimally train them to prescribe. We therefore aimed to explore the experiences and attitudes of residents learning to prescribe buprenorphine within two primary care-based opioid treatment models. We performed semi-structured interviews with second- and third-year internal medicine residents at an urban academic residency program. Participating residents practiced in clinics providing buprenorphine care using either a nurse care manager model or a provider-centric model. Subjects were sampled purposively to ensure that a diversity of perspectives were included. Interviews were conducted until theoretical saturation was reached and were analyzed using principles of thematic analysis. The research team developed a consensus code list. Each transcript was then independently coded by two researchers. The team then summarized each code and generated a set of themes that captured the main ideas emerging from the data. We completed 14 interviews. Participants reported learning to prescribe buprenorphine through didactics, longitudinal outpatient prescribing, mentorship, and inpatient experiences. We characterized their attitudes toward patients with OUD, medication treatment of OUD, their own role in buprenorphine care, and future prescribing. Participants practicing in both clinical models viewed learning to prescribe buprenorphine as a normal part of their training and demonstrated positive attitudes toward buprenorphine prescribing. Longitudinal outpatient experiences with buprenorphine prescribing can prepare residents to prescribe buprenorphine and stimulate interest in prescribing after residency. Both nurse care manager and provider-centric clinical models can provide meaningful experiences for medical residents. Educators should attend to the volume of patients and inductions managed by each trainee, patient-provider continuity, and supporting trainees in the clinical encounter.

BACKGROUND

The large-scale social distancing efforts to reduce SARS-CoV-2 transmission have dramatically changed human behaviors associated with traumatic injuries. Trauma centers have reported decreases in trauma volume, paralleled by changes in injury mechanisms. We aimed to quantify changes in trauma epidemiology at an urban Level I trauma center in a county that instituted one of the earliest shelter-in-place orders to inform trauma care during future pandemic responses.

METHODS

A single-center interrupted time-series analysis was performed to identify associations of shelter-in-place with trauma volume, injury mechanisms, and patient demographics in San Francisco, California. To control for short-term trends in trauma epidemiology, weekly level data were analyzed 6 months before shelter-in-place. To control for long-term trends, monthly level data were analyzed 5 years before shelter-in-place.

RESULTS

Trauma volume decreased by 50% in the week following shelter-in-place (p < 0.01), followed by a linear increase each successive week (p < 0.01). Despite this, trauma volume for each month (March-June 2020) remained lower compared with corresponding months for all previous 5 years (2015-2019). Pediatric trauma volume showed similar trends with initial decreases (p = 0.02) followed by steady increases (p = 0.05). Reductions in trauma volumes were due entirely to changes in nonviolent injury mechanisms, while violence-related injury mechanisms remained unchanged (p < 0.01).

CONCLUSION

Although the shelter-in-place order was associated with an overall decline in trauma volume, violence-related injuries persisted. Delineating and addressing underlying factors driving persistent violence-related injuries during shelter-in-place orders should be a focus of public health efforts in preparation for future pandemic responses.

LEVEL OF EVIDENCE

Epidemiological study, level III.