BackgroundFood insecurity, the uncertain ability to access adequate food, can limit adherence to dietary measures needed to prevent and manage cardiometabolic conditions. However, little is known about temporal trends in food insecurity among those with diet-sensitive cardiometabolic conditions.MethodsWe used data from the Continuous National Health and Nutrition Examination Survey (NHANES) 2005–2012, analyzed in 2015–2016, to calculate trends in age-standardized rates of food insecurity for those with and without the following diet-sensitive cardiometabolic conditions: diabetes mellitus, hypertension, coronary heart disease, congestive heart failure, and obesity.Results21,196 NHANES participants were included from 4 waves (4,408 in 2005–2006, 5,607 in 2007–2008, 5,934 in 2009–2010, and 5,247 in 2011–2012). 56.2% had at least one cardiometabolic condition, 24.4% had 2 or more, and 8.5% had 3 or more. The overall age-standardized rate of food insecurity doubled during the study period, from 9.06% in 2005–2006 to 10.82% in 2007–2008 to 15.22% in 2009–2010 to 18.33% in 2011–2012 (p for trend < .001). The average annual percentage change in food insecurity for those with a cardiometabolic condition during the study period was 13.0% (95% CI 7.5% to 18.6%), compared with 5.8% (95% CI 1.8% to 10.0%) for those without a cardiometabolic condition, (parallelism test p = .13). Comparing those with and without the condition, age-standardized rates of food insecurity were greater in participants with diabetes (19.5% vs. 11.5%, p < .0001), hypertension (14.1% vs. 11.1%, p = .0003), coronary heart disease (20.5% vs. 11.9%, p < .001), congestive heart failure (18.4% vs. 12.1%, p = .004), and obesity (14.3% vs. 11.1%, p < .001).ConclusionsFood insecurity doubled to historic highs from 2005–2012, particularly affecting those with diet-sensitive cardiometabolic conditions. Since adherence to specific dietary recommendations is a foundation of the prevention and treatment of cardiometabolic disease, these results have important implications for clinical management and public health.

Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.

This pilot study assessed feasibility of videoenhanced care management for complex older veterans with suspected mild cognitive impairment (CI) and their care partners, compared with telephone delivery. DESIGN: Pilot randomized controlled trial. SETTING: Durham Veterans Affairs Health Care System. PARTICIPANTS: Participants were enrolled as dyads, consisting of veterans aged 65 years or older with complex medical conditions (Care Assessment Need score ≥90) and suspected mild CI (education-adjusted Modified Telephone Interview for Cognitive Status score 20-31) and their care partners. INTERVENTION: The 12-week care management intervention consisted of monthly calls from a study nurse covering medication management, cardiovascular disease risk reduction, physical activity, and sleep behaviors, delivered via video compared with telephone.MEASUREMENTS: Dyads completed baseline and follow-up assessments to assess feasibility, acceptability, and usability. RESULTS: Forty veterans (mean (standard deviation (SD)) age = 72.4 (6.1) years; 100% male; 37.5% Black) and their care partners (mean (SD) age = 64.7 (10.8) years) were enrolled and randomized to telephone or video-enhanced care management. About a third of veteran participants indicated familiarity with relevant technology (regular tablet use and/or experience with videoconferencing); 53.6% of internet users were comfortable or very comfortable using the internet. Overall, 43 (71.7%) care management calls were completed in the video arm and 52 (86.7%) were completed in the telephone arm. Usability of the video telehealth platform was rated higher for participants already familiar with technology used to deliver the intervention (mean (SD) System Usability Scale scores: 65.0 (17.0) vs 55.6 (19.6)). Veterans, care partners, and study nurses reported greater engagement, communication, and interaction in the video arm. CONCLUSION: Video-delivered care management calls were feasible and preferred over telephone for some complex older adults with mild CI and their care partners. Future research should focus on understanding how to assess and incorporate patient and family preferences related to uptake and maintenance of video telehealth interventions.

Objective This study aims to describe geographic variation in veterans’ prevalence of obesity, participation in Veterans Health Administration’s behavioral weight management program (MOVE!), and receipt of bariatric surgery in fiscal year (FY) 2016. Methods In this retrospective cohort study of veterans with obesity who received Veterans Health Administration care in FY2016, electronic health record data were obtained on weight, height, outpatient visits to the MOVE! program, and bariatric surgeries. For each Veterans Integrated Service Network (VISN) region, the prevalence rate of veterans with obesity (BMI ≥ 30 kg/m2), MOVE! participation rates, and bariatric surgery rates are presented. Results The prevalence of obesity in veterans ranged from 30.5% to 40.5% across VISNs in FY2016. MOVE! participation among veterans with obesity was low (2.8%‐6.9%) across all VISNs, but veterans with class II and III obesity (BMI ≥ 35) had higher MOVE! participation rates (4.3%‐10.8%) than veterans with class I obesity. There was 20‐fold variation across VISNs in receipt of bariatric surgery among veterans with BMI ≥ 35, ranging from 0.01% to 0.2%. Among veterans with BMI ≥ 35 participating in MOVE!, there was 46‐fold variation in bariatric surgery provision, ranging from 0.07% to 3.27%. Conclusions Despite veterans’ high prevalence of obesity, behavioral and surgical weight management participation is low and varies across regions.

This cohort study examines the long-term risk of developing alcohol abuse or dependence among a predominantly male bariatric population who underwent either a laparoscopic sleeve gastrectomy or a Roux-en-Y gastric bypass.

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IMPORTANCE Bariatric surgery has been associated with improvements in health in patients with severe obesity; however, it is unclear whether these health benefits translate into lower health care expenditures. OBJECTIVE To examine 10-year health care expenditures in a large, multisite retrospective cohort study of veterans with severe obesity who did and did not undergo bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS A total of 9954 veterans with severe obesity between January 1, 2000, and September 30, 2011, were identified from veterans affairs (VA) electronic health records. Of those, 2498 veterans who underwent bariatric surgery were allocated to the surgery cohort. Sequential stratification was used to match each patient in the surgery cohort with up to 3 patients who had not undergone bariatric surgery but were of the same sex, race/ethnicity, diabetes status, and VA regional network and were closest in age, body mass index (calculated as weight in kilograms divided by height in meters squared), and comorbidities. A total of 7456 patients were identified and allocated to the nonsurgery (control) cohort. The VA health care expenditures among the surgery and nonsurgery cohorts were estimated using regression models. Data were analyzed from July to August 2018 and in April 2019. INTERVENTIONS The bariatric surgical procedures (n = 2498) included in this study were Roux-en-Y gastric bypass (1842 [73.7%]), sleeve gastrectomy (381 [15.3%]), adjustable gastric banding (249 [10.0%]), and other procedures (26 [1.0%]). MAIN OUTCOMES AND MEASURES The study measured total, outpatient, inpatient, and outpatient pharmacy expenditures from 3 years before surgery to 10 years after surgery, excluding expenditures associated with the initial bariatric surgical procedure. RESULTS Among 9954 veterans with severe obesity, 7387 (74.2%) were men; the mean (SD) age was 52.3 (8.8) years for the surgery cohort and 52.5 (8.

Background Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. MethodsWe examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. ResultsOverall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings.Conclusions Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.