Rani Elwy

Our objective was to review systematically studies of interventions to prevent transmission of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) in heterosexual men. Of 1157 studies identified through database and hand searching, 27 met our inclusion criteria. Most interventions targeted specific groups of men (eg, those attending STI clinics) rather than general populations. Few were conducted with men alone, and most focused on behavioral and social psychological rather than morbidity outcomes. Of 8 interventions designed to reduce STI incidence (including HIV), 5 were successful, 2 were unsuccessful, and 1 had equivocal results. Of the 5 successful interventions, 1 was carried out in the workplace, 1 in the military, and 3 in STI clinics.They included on-site individual counseling and HIV testing, mass communications regarding risk reduction, and multiple-component motivation and skills education in STI clinics. More high-quality research into the effectiveness of interventions targeting heterosexual men is needed, especially methodologically sound trials to evaluate effects on morbidity.

Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home pract...

Outcome for mental health conditions is suboptimal, and care is fragmented. Evidence from controlled trials indicates that collaborative chronic care models (CCMs) can improve outcomes in a broad array of mental health conditions. US Department of Veterans Affairs leadership launched a nationwide initiative to establish multidisciplinary teams in general mental health clinics in all medical centers. As part of this effort, leadership partnered with implementation researchers to develop a program evaluation protocol to provide rigorous scientific data to address two implementation questions: (1) Can evidence-based CCMs be successfully implemented using existing staff in general mental health clinics supported by internal and external implementation facilitation? (2) What is the impact of CCM implementation efforts on patient health status and perceptions of care? Health system operation leaders and researchers partnered in an iterative process to design a protocol that balances opera...

Yoga interventions have considerable heterogeneity, are multi-dimensional, and may impact health in different ways. However, most research reports regarding the effects of yoga on health and wellbeing do not adequately describe the components of the yoga interventions being used. Thus, drawing comparisons across studies or understanding the relative effects of specific aspects of a yoga intervention are rarely possible. To address this problem, we created the Essential Properties of Yoga Questionnaire (EPYQ) Project, an NCCAM-funded set of studies to develop a translational tool for yoga researchers. Here we describe the methods and developmental processes used in the EPYQ Project in detail. The project consists of four main phases. Phase I was designed to gain a comprehensive understanding of the relevant aspects of yoga by conducting a comprehensive systematic literature review and conducting focus groups with stakeholders including a wide variety of yoga teachers and students. In...

How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE. We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45 274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns. Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percenta...

The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy. Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures. Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place. Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members. Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation. Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities' needs (evaluation). Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

ABSTRACT The Veterans Health Administration (VHA) mandates annual depression screening in primary care; however, veterans often delay seeking treatment after screening positive, which can increase the severity and impact of depression. This mixed-methods study examined the association between stigma and treatment utilization among veterans (N = 271) in primary care with a positive depression screen. A subsample of veterans (N = 23) participated in a semistructured interview to qualitatively explore the social and cultural contexts of treatment utilization for depression. Treatment utilization data based on Healthcare Effectiveness Data and Information Set (HEDIS) guidelines were obtained by chart review 3 months following the positive screen date. Logistic regression indicated a lack of evidence that stigma was associated with treatment utilization. However, grounded thematic analysis suggested that stigma negatively influenced perceptions of depression and treatment utilization for some veterans. Four themes emerged: (1) depression is weakness; (2) depression is an unwanted label; (3) depression is normal; and (4) overcoming stigma. Evidence from interviews suggests that stigma may play a larger role in decisions about treatment seeking, which was not quantitatively evident. Addressing the psychosocial ramifications of stigma for depression may help minimize treatment lapses and maximize treatment seeking among veterans who screen positive for depression in primary care.

Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment. We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

... in female and male OEF/OIF veterans" by Dawne Vogt, Brian Smith, Rani Elwy, James Martin, Mark Schultz, Mari-Lynn Drainoni and ... Freedom (OIF), as well as to examine the extent to which results mirror associations observed among Vietnam Veterans (King, King, Foy, Keane ...

Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Yet, the research on mind and body practices has been critiqued as being too limited in evidence and scope to inform clinical treatment. We conducted a systematic scoping review of mind and body practices used with veterans or active duty military personnel to identify gaps in the literature and make recommendations for future primary research. Following systematic literature review methodology, we searched 5 databases using 27 different National Center for Complementary and Alternative Medicine-defined mind and body practices as text words, keywords, and MeSH terms through June 30, 2014. We also conducted handsearches of 4 previous reviews. Active duty military members or veterans 18 years or older participating in mind and body practice interventions globally. Data were extracted from studies meeting 5 inclusion criteria. The quality of randomized controlled trials (RCTs) was assessed using an existing checklist. Of 1819 studies identified, 89 interventions (50 RCTs) published between 1976 and 2014, conducted in 9 countries, using 152 different measures to assess 65 health and well-being outcomes met our inclusion criteria. Most interventions took place in the United States (n=78). Meditation practices (n=25), relaxation techniques including imagery (n=20), spinal manipulation including physical therapy (n=16), and acupuncture (n=11) were the most frequently studied practices. Methodological quality of most RCTs was rated poorly. Meditation and acupuncture practices are among the most frequently offered and studied mind and body practices. Future research should include yoga as it is currently understudied among veterans and military personnel. A repository of mind and body intervention outcome measures may further future research efforts, as would conducting pragmatic trials and more robust RCTs.