U.S. Department of Veterans Affairs. (PROSPERO: CRD42016033623).

Background The COVID-19 pandemic resulted in unprecedented adjustments to intensive care unit (ICU) organization and care processes globally. Research Question Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting; which strategies worked well to mitigate strain as perceived by intensivists? Study Design and Methods : Between August-November 2020, we performed semi-structured interviews of intensivists from tertiary and community hospitals across six regions in the United States (U.S.) that experienced early and/or large surges of COVID-19 patients. We identified themes of hospital emergency responses using the “four S framework” of acute surge planning (i.e., Space, Staff, Stuff, System). Results 33 intensivists from 7 tertiary and 6 community hospitals participated. Clinicians across both settings felt that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly-defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and re-use were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians’ anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped maintain trust among staff. Interpretation We identified several strategies to potentially mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrates the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016033623).

ImportanceThere is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems.ObjectiveTo describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9).Design, Setting, and ParticipantsThis qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022.Main Outcomes and MeasuresA text word search and qualitative analysis of patients’ VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID.ResultsIn this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients’ EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post–COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients.Conclusions and RelevanceThis qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.

No abstract

Introduction Women Veterans of the Persian Gulf War (GW) expanded the military roles they had filled in previous military eras, with some women engaging in direct combat for the first time. Many GW service members, including women, had unique combat exposures to hazardous agents during deployment, which might have contributed to the development of chronic health problems. This study aims to understand the experiences of women GW Veterans (GWVs) as it is related to their military service and subsequent health in order to better inform and improve their clinical care. Materials and Methods We conducted in-depth interviews with 10 women GWVs to understand their experiences and perspectives about how their military service in the Gulf has impacted their lives and health. We used an integrated approach of content analysis and inductive thematic analysis to interpret interview data. Results Besides having many of the same war-related exposures as men, women faced additional challenges in a military that was inadequately prepared to accommodate them, and they felt disadvantaged as women within the military and local culture. After service, participants had emergent physical and mental health concerns, which they described as developing into chronic and complex conditions, affecting their relationships and careers. While seeking care and service connection at Veterans Health Administration (VA), women voiced frustration over claim denials and feeling dismissed. They provided suggestions of how VA services could be improved for women and GWVs. Participants found some nonpharmacological approaches for symptom management and coping strategies to be helpful. Conclusions Women in the GW encountered challenges in military and healthcare systems that were inadequately prepared to address their needs. Women faced chronic health conditions common to GWV and voiced the desire to be understood as a cohort with unique needs. There is an ongoing need to expand services within the VA for women GWVs, particularly involving psychosocial support and management of chronic illness. While the small sample size can limit generalizability, the nature of these in-depth, minimally guided interviews provides a rich narrative of the women GWVs in this geographically diverse sample.

There are potential risks associated with co-occurring LTOT and medical cannabis for pain. Study findings highlight the need for further clinical evaluation in this population. Future research is needed to examine the longitudinal impact of medical cannabis use on pain-related and substance use outcomes.

Objective The purpose of this study is to examine the extent to which Numeric Rating Scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health related quality of life (HRQOL). Design We conducted a secondary analysis of data from a prospective cohort study. Subjects We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. Setting VA Portland Health Care System outpatient clinic. Methods All patients had been screened with the 0–10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every six months for two years. Accounting for non-independence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes. Results NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B’s = 0.53–0.59) and modestly associated with pain disability scores (B’s = 0.33–0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B’s = 0.09–0.26, with the preponderance of B’s < 0.20). Conclusions Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.