VA Sierra Pacific Network

The present study examined the temporal relationship between posttraumatic stress disorder (PTSD) and social support among 128 male veterans treated for chronic PTSD. Level of perceived interpersonal support and stressors were assessed at two time points (6 months apart) for four different potential sources of support: spouse, relatives, nonveteran friends, and veteran peers. Veteran peers provided relatively high perceived support and little interpersonal stress. Spouses were seen as both interpersonal resources and sources of interpersonal stress. More severe PTSD symptoms at Time 1 predicted greater erosion in perceived support from nonveteran friends, but not from relatives. Contrary to expectations, initial levels of perceived support and stressors did not predict the course of chronic PTSD symptoms.

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

This article distills from available data descriptions of typical human symptoms in reaction to prompt total-body ionizing radiation in the dose range 0.5 to 30 Gy midline body tissue. The symptoms are correlated with dose and time over the acute postexposure period of 6 wk. The purpose is to provide a symptomatology basis for assessing early functional impairment of individuals who may be involved in civil defense, emergency medical care and various military activities in the event of a nuclear attack. The dose range is divided into eight subranges associated with important pathophysiological events. For each subrange, signs and symptoms are designated including estimates of symptom onset, severity, duration and incidence.

Little is known about how recent ISTSS practice guidelines (E. B. Foa, T. M. Keane, & M. J. Friedman, 2000) compare with prevailing PTSD treatment practices for veterans. Prior to guideline dissemination, clinicians in 6 VA medical centers were surveyed in 1999 (n = 321) and in 2001 (n = 271) regarding their use of various assessment and treatment procedures. Practices most consistent with guideline recommendations included psychoeducation, coping skills training, attention to trust issues, depression and substance use screening, and prescribing of SSRIs, anticonvulsants, and trazodone. PTSD and trauma assessment, anger management, and sleep hygiene practices were provided less consistently. Exposure therapy was rarely used. Additional research is needed on training, clinical resources, and organizational factors that may influence VA implementation of guideline recommendations.

A new approach to wide area surveillance is described that is based on the detection and analysis of changes across two or more images over time. Methods for modeling and detecting general patterns of change associated with construction and other kinds of activities that can be observed in remotely sensed imagery are presented. They include a new nonlinear prediction technique for measuring changes between images and temporal segmentation and filtering techniques for analyzing patterns of change over time. These methods are applied to the problem of detecting facility construction using Landsat Thematic Mapper imagery. Full scene results show the methods to be capable of detecting specific patterns of change with very few false alarms. Under all conditions explored, as the number of images used increases, the number of false alarms decreases dramatically without affecting the detection performance. It is argued that the processing gain that results in using more than two images justifies the increased computational complexity and storage requirements of our approach over single image object detection and conventional change detection techniques.

Abstract Rationale Obstructive sleep apnea (OSA) is a common sleep disorder for which the principal treatment option, continuous positive airway pressure, is often poorly tolerated. There is currently no approved pharmacotherapy for OSA. However, recent studies have demonstrated improvement in OSA with combined antimuscarinic and noradrenergic drugs. Objectives The aim of this study was to evaluate the efficacy and safety of AD109, a combination of the novel antimuscarinic agent aroxybutynin and the norepinephrine reuptake inhibitor atomoxetine, in the treatment of OSA. Methods Phase II randomized, double-blind, placebo-controlled, parallel-group, 4-week trial comparing AD109 2.5/75 mg, AD109 5/75 mg, atomoxetine 75 mg alone, and placebo (www.clinicaltrials.gov identifier NCT 05071612). Measurements and Main Results Of 211 randomized patients, 181 were included in the prespecified efficacy analyses. Sleep was assessed by two baseline and two treatment polysomnograms. Apnea–hypopnea index with a 4% desaturation criterion (primary outcome) was reduced from a median (IQR) of 20.5 (12.3–27.2) to 10.8 (5.6–18.5) in the AD109 2.5/75 mg arm (−47.1%), from 19.4 (13.7–26.4) to 9.5 (6.1–19.3) in the AD109 5/75 mg arm (−42.9%; both P &amp;lt; 0.0001 vs. placebo), and from 19.0 (11.8–28.8) to 11.8 (5.5–21.5) with atomoxetine alone (−38.8%; P &amp;lt; 0.01 vs. placebo). Apnea–hypopnea index with a 4% desaturation criterion decreased from 20.1 (11.9–25.9) to 16.3 (11.1–28.9) in the placebo arm. Subjectively, there was improvement in fatigue with AD109 2.5/75 mg (P &amp;lt; 0.05 vs. placebo and atomoxetine). Atomoxetine taken alone decreased total sleep time (P &amp;lt; 0.05 vs. AD109 and placebo). The most common adverse events were dry mouth, insomnia, and urinary hesitancy. Conclusions AD109 showed clinically meaningful improvement in OSA, suggesting that further development of the compound is warranted. Clinical trial registered with www.clinicaltrials.gov (NCT 05071612).

OBJECTIVE: The effect of the COVID-19 pandemic on community-based rheumatology care and the use of telehealth is unclear. We undertook this study to investigate the impact of the pandemic on rheumatology care delivery in a large community practice-based network. METHODS: Using a community practice-based rheumatologist network, we examined trends in in-person versus telehealth visits versus canceled visits in 3 time periods: pre-COVID-19, COVID-19 transition (6 weeks beginning March 23, 2020), and post-COVID-19 transition (May-August). In the transition period, we compared patients who received in-person care versus telehealth visits versus those who cancelled all visits. We used multivariable logistic regression to identify factors associated with canceled or telehealth visits. RESULTS: Pre-COVID-19, there were 7,075 visits/week among 60,002 unique rheumatology patients cared for by ~300 providers practicing in 92 offices. This number decreased substantially (24.6% reduction) during the COVID-19 transition period for in-person visits but rebounded to pre-COVID-19 levels during the post-COVID-19 transition. There were almost no telehealth visits pre-COVID-19, but telehealth increased substantially during the COVID-19 transition (41.4% of all follow-up visits) and slightly decreased during the post-COVID-19 transition (27.7% of visits). Older age, female sex, Black or Hispanic race/ethnicity, lower socioeconomic status, and rural residence were associated with a greater likelihood of canceling visits. Most factors were also associated with a lower likelihood of having telehealth versus in-office visits. Patients living further from the rheumatologists' office were more likely to use telehealth. CONCLUSION: COVID-19 led to large disruptions in rheumatology care; these disruptions were only partially offset by increases in telehealth use and disproportionately affected racial/ethnic minorities and patients with lower socioeconomic status. During the COVID-19 era, telehealth continues to be an important part of rheumatology practice, but disparities in access to care exist for some vulnerable groups.

BACKGROUND: Varenicline is a selective nicotinic receptor partial agonist used to aid in the process of smoking cessation. Research on varenicline's approval for marketing demonstrated that after 12 weeks of treatment, at least 44% of patients successfully quit smoking and, on average, 13% of individuals discontinued therapy due to an adverse drug event (ADE). Growing postmarketing data linked varenicline to an increase in neuropsychiatric symptoms. OBJECTIVE: To evaluate the safety profile, specifically psychiatric symptoms, and effectiveness of varenicline in a veteran population and to determine whether there is an association among specific baseline demographics and success rate. METHODS: The study was a retrospective review of a prospective performance measure involving veterans initiated on varenicline. Patients were contacted via telephone throughout treatment and at week 12 for effectiveness follow-up. Smoking history was obtained and medication counseling was provided. The primary endpoint was tobacco cessation between weeks 9 and 12 of therapy. Varenicline's safety profile and discontinuation rates due to ADEs were also analyzed. RESULTS: Of the 50 patients included in the study, 30% (n = 15) successfully quit smoking and 70% (n = 35) failed therapy (lack of effectiveness, n = 22; intolerability, n = 13). Prevalence of underlying mental illness in the success group (4/15; 27%) versus failure group (20/35; 57%) was statistically significant (p < 0.001). All patients who discontinued therapy due to an increase in mood and behavioral changes (n = 4) had an underlying psychiatric illness. The study results demonstrate a lower success rate and a higher incidence of discontinuation due to an ADE in our veteran population compared with premarketing data. An inverse association was shown between psychiatric disorders and success. CONCLUSIONS: Cautious treatment initiation and close monitoring of veterans initiated on varenicline are warranted. Furthermore, the results from this study demonstrate the need for prospective effectiveness trials to determine the clinical significance of the results.

PURPOSE: The process and operational elements to establish a population health program using electronic medical record data in a Veterans Health Administration region are described. SUMMARY: Pharmacists are uniquely qualified to assume important roles in population health through the use of their clinical knowledge, assisted by electronic tools that consolidate and report patient-specific data for clinical care. Veterans Integrated Services Network (VISN) 21 has developed 300 dashboards and reports to improve the quality, safety, and value of healthcare to veterans. Within a group of specialty task forces, physicians, nurses, and pharmacists assist in the design and development of evidence-based tools to leverage timely electronic health information into metrics, benchmarks, and targets to assist with goal achievement. Examples of programs designed to improve care in 3 areas were selected for further description and review of outcomes. Population health improvement using Healthcare Effectiveness Data and Information Set and hepatitis C metrics were used to describe populations that may have an indication for evidence-based care but are not receiving it. Deprescribing efforts are described, as are medication safety monitoring efforts to prevent potential adverse events known to be associated with therapy. CONCLUSION: Quality, safety, and value outcomes are the measures of success for population health programs in VISN 21. Data-rich project dashboards and reports are developed by pharmacist data analysts and implemented and used by teams of clinicians who provide continuous feedback and support to improve population health. The use of task forces, metrics, benchmarks, targets, and teams is instrumental in the successful application of these tools.

BACKGROUND: Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care. METHODS: Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these "data-driven" implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs' use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care. DISCUSSION: Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices. TRIAL REGISTRATION: This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

Objective: Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA). Design: Qualitative process evaluation using semistructured interviews. Setting: Seven VA health care systems in the Sierra Pacific region. Subjects: Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20). Methods: Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research. Results: Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources. Conclusions: Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

BACKGROUND: While few countries and healthcare systems are on track to meet the World Health Organization's hepatitis C virus (HCV) elimination goals, the US Veterans Health Administration (VHA) has been a leader in these efforts. We aimed to determine which implementation strategies were associated with successful national viral elimination implementation within the VHA. METHODS: We conducted a five-year, longitudinal cohort study of the VHA Hepatic Innovation Team (HIT) Collaborative between October 2015 and September 2019. Participants from 130 VHA medical centers treating HCV were sent annual electronic surveys about their use of 73 implementation strategies, organized into nine clusters as described by the Expert Recommendations for Implementing Change taxonomy. Descriptive and nonparametric analyses assessed strategy use over time, strategy attribution to the HIT, and strategy associations with site HCV treatment volume and rate of adoption, following the Theory of Diffusion of Innovations. RESULTS: Between 58 and 109 medical centers provided responses in each year, including 127 (98%) responding at least once, and 54 (42%) responding in all four implementation years. A median of 13-27 strategies were endorsed per year, and 8-36 individual strategies were significantly associated with treatment volume per year. Data warehousing, tailoring, and patient-facing strategies were most commonly endorsed. One strategy-"identify early adopters to learn from their experiences"-was significantly associated with HCV treatment volume in each year. Peak implementation year was associated with revising professional roles, providing local technical assistance, using data warehousing (i.e., dashboard population management), and identifying and preparing champions. Many of the strategies were driven by a national learning collaborative, which was instrumental in successful HCV elimination. CONCLUSIONS: VHA's tremendous success in rapidly treating nearly all Veterans with HCV can provide a roadmap for other HCV elimination initiatives.

PURPOSE: The establishment and outcomes of a model primary care pharmacy service system are described. SUMMARY: A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs. CONCLUSION: A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.

BACKGROUND AND AIMS: The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention. APPROACH AND RESULTS: VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews. CONCLUSIONS: In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology.

After implementing a successful hepatitis C elimination program, the Veterans Health Administration’s (VHA) Hepatic Innovation Team (HIT) Collaborative pivoted to focus on improving cirrhosis care. This national program developed teams of providers across the country and engaged them in using systems redesign methods and population health approaches to improve care. The HIT Collaborative developed an Advanced Liver Disease (ALD) Dashboard to identify Veterans with cirrhosis who were due for surveillance for hepatocellular carcinoma (HCC) and other liver care, promoted the use of an HCC Clinical Reminder in the electronic health record, and provided training and networking opportunities. This evaluation aimed to describe the VHA’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates, using a quasi-experimental design. Across all VHA facilities, as the HIT focused on cirrhosis between 2018–2019, HCC surveillance rates increased from 46% (IQR 37–53%) to 51% (IQR 42–60%, p &lt; 0.001). The median HCC surveillance rate was 57% in facilities with high ALD Dashboard utilization compared with 45% in facilities with lower utilization (p &lt; 0.001) and 58% in facilities using the HCC Clinical Reminder compared with 47% in facilities not using this tool (p &lt; 0.001) in FY19. Increased use of the ALD Dashboard and adoption of the HCC Clinical Reminder were independently, significantly associated with HCC surveillance rates in multivariate models, controlling for other facility characteristics. In conclusion, the VHA’s HIT Collaborative is a national healthcare initiative associated with significant improvement in HCC surveillance rates.

Joseph T. DiPiro, PharmD, FCCP, FAAAS, Dean, School of Pharmacy, Virginia Commonwealth University, Richmond, VA Address correspondence to Dr. DiPiro (ude.ucv@oripidtj). An underlying assumption supporting the need for the Pharmacy Forecast is that many factors influencing our profession and pharmacy services are not directly under our control, yet we can take actions that enhance the likelihood of favorable outcomes within this environment. Those influencing factors may be as a specific state or national policy or regulation, or as nebulous as the trend toward globalization (or anti-globalization). Other than the COVID-19 pandemic, the influencing factors such as the prominence of “big data,” issues of personal privacy, financing and health access are not new and have emerged over time. Within that context, then, we have greatest control over the scope of our pharmacy enterprise and the workforce within that enterprise, and some control over those factors where we can advocate to the decision makers (such as health-system administrators, legislators, and government agency officials). The perspective gained from reading the 2021 Pharmacy Forecast is most effectively used within the process of strategic planning as part of environmental scanning or when identifying strengths, weaknesses, opportunities, or threats (SWOT). In addition, the recommendations provided below can be part of the institution’s strategic planning action steps. FORECAST METHODS The methods used to develop the 2021 Pharmacy Forecast were similar to those used in the previous editions, drawing on concepts described in James Surowiecki’s book The Wisdom of Crowds.1 According to Surowiecki, the collective opinions of “wise crowds”—groups of diverse individuals in which each participant’s input is provided independently, drawing from their own locally informed points of view—can be more informative than the opinion of any individual participant. This process is particularly valuable when addressing phenomena that are not well suited to quantitative predictive methods. A critical requirement for successfully creating crowd-based knowledge is establishing a systematic method of combining individual beliefs into a collective opinion—the Pharmacy Forecast uses a survey of carefully selected pharmacy leaders to derive our environmental scan. The 2021 Pharmacy Forecast Advisory Committee (see membership list in the Foreword) began the development of survey questions by contributing lists of issues and concerns they believed will influence health-system pharmacy in the coming 5 years. That list was then expanded and refined through an iterative process, resulting in a final set of 7 themes, each with 6 focused topics on which the survey was built. Each of 42 survey items was written to explore the selected topics and was pilot tested to ensure clarity and face validity. As in the past, Pharmacy Forecast survey respondents—the Forecast Panelists (FPs)—were selected by ASHP staff after nomination by the leaders of the ASHP sections. Nominations were limited to individuals known to have expertise in health-system pharmacy and knowledge of trends and new developments in the field. The size of and representation within the Forecast Panel were intended to capture opinions from a wide range of pharmacy leaders. The Pharmacy Forecast survey instructed FPs to read each of the 42 scenarios represented in survey items and consider the likelihood of those scenarios occurring in the next 5 years. They were asked to base their response on their firsthand knowledge of current conditions in their region, not on their understanding of national circumstances. The panel was carefully balanced across the census regions of the United States to reflect a representative national picture. They were asked to provide a top-of-mind response regarding the likelihood of those conditions being very likely, somewhat likely, somewhat unlikely, or very unlikely to occur. This year we chose to present (in related articles in this issue of AJHP) additional insights on Pharmacy Forecast topics in the light of major societal factors, the U.S. presidential election, the COVID-19 pandemic, and racial equity and social justice within our country. William Zellmer was invited to reflect on the developing political environment after our national election and how it could impact healthcare.2 Suzanne Shea was invited to address the effects of the COVID-19 pandemic on selected topics within the Pharmacy Forecast survey.3 And Bruce Scott was invited to address the intersection of racial equity and healthcare.4

National healthcare policy is affecting the way health systems provide care by mandating accountability through standardized performance measures and incentives for improvement. Health systems are responding by adopting management systems—in many cases, systems from other industries—to measure process and patient outcomes. Studying value streams to improve daily management systems and goal attainment is now becoming more common with increased efforts to measure and improve complex healthcare delivery systems. Many healthcare systems are focused on service improvement models to train and engage both employees and patients and to implement the changes needed to improve our healthcare system. These newly embedded “integrated practices” are designed to improve quality, safety, and value. As changes occur in healthcare, the missions and goals of healthcare systems are shifting. In fact, changes are occurring so rapidly that many systems may have difficulty articulating and achieving health-system goals effectively. However, there is no lack of suggested performance measures and metrics from many sources.

A study of the 3- μm laser transitions in Ho:YAlO <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">3</sub> and Nd,Ho:YAlO <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">3</sub> using both flashlamp and laser pumping is discussed. Fluorescence measurements for the Nd,Ho:YAlO <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">3</sub> rod indicate that the neodymium is effective in quenching the lower holmium laser level and in sensitizing the upper level. Intracavity laser pumping of Ho:YAlO <sub xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">3</sub> produced laser lines at 2.92 and 2.85 μm and demonstrated high efficiency.

BACKGROUND: Chronic opioid therapy-clinical reminder (COT-CR) is a decision support tool to prompt providers to carefully assess patients prescribed chronic opioids. This tool was developed to address inappropriate opioid prescribing. OBJECTIVE: To determine COT-CR's impact on reducing morphine equivalent monthly dose (MEMD) and risk index for overdose or serious prescription opioid-induced respiratory depression (RIOSORD) values in veterans receiving chronic opioids. METHODS: This retrospective cohort review matched patients with a complete COT-CR to patients with an incomplete COT-CR using propensity scores. In the primary aim, an interrupted time series design evaluated for changes in MEMD 12 months before and 6 months after the index date. The index date was the first pain or primary care provider visit post COT-CR installation. In the secondary aims, a retrospective cohort design was used to evaluate the changes in RIOSORD index score and risk class 6 months after the index date. RESULTS: After matching, 3801 patients were included in the complete and incomplete COT-CR groups, respectively. Greater average reduction in MEMD (-11.6 MEMD; 95% CI = -0.97 to -22.25 MEMD; P = 0.032) and RIOSORD index score (-0.53 RIOSORD index score; 95% CI = -1.00, -0.05 RIOSORD index score; P = 0.030) was observed in patients with a complete COT-CR compared to patients with an incomplete COT-CR. Differences in RIOSORD risk class were insignificant. CONCLUSION: Completing the COT-CR was associated with reduced MEMD and RIOSORD values. This suggests that active monitoring can change prescribing patterns, thereby, reducing the overall risk of opioid overdose in at-risk veterans.

BACKGROUND: Screening for colorectal cancer (CRC) with faecal immunochemical test (FIT) is effective at reducing CRC mortality. Unfortunately, the COVID-19 pandemic has been associated with deferred care, especially screening for CRC. AIM: We sought to develop a mailed FIT programme (MFP) to increase CRC screening and make recommendations for adoption across the Veterans Health Administration (VHA) and for other large healthcare systems. SETTING: 2 regional VA medical centres in California and Washington state. PARTICIPANTS: 5667 average risk veterans aged 50-75 overdue or due within 90 days for CRC screening. PROGRAMME DESCRIPTION: A multidisciplinary implementation team collaborated to mail an FIT kit to eligible veterans. Both sites mailed a primer postcard, and one site added an automated reminder call. PROGRAMME EVALUATION: We monitored FIT return and positivity rate, as well as impact of the programme on clinical staff. 34% of FIT kits were returned within 90 days and 7.8% were abnormal. DISCUSSION: We successfully implemented a population-based MFP at multiple regional VA sites and recommend that these efforts be spread across VA. Our model of regional leadership, facility champions and using centralised resources can be adaptable to other large healthcare systems. MFPs support catch-up from disrupted care by addressing access to CRC screening, unburden primary care visits and conserve limited procedural resources.