Vaughan‐Sarrazin, Mary

AbstractBackgroundIdentifying patient‐, facility‐, and environment‐level factors that influence the initiation and retention of comprehensive lifestyle management interventions (CLMI) for urban and rural Veterans could improve obesity treatment and reach at Veterans Affairs (VA) facilities.AimsThis study identified factors at these various levels that predicted treatment engagement, retention, and weight management among urban and rural Veterans.MethodsA retrospective cohort study of 631,325 Veterans was designed using VA databases to identify Veterans with class II and III obesity during 2015–2017. Primary outcomes were initiation of CLMI, bariatric surgery, or obesity pharmacotherapy within 1 year of index date. Secondary outcomes included treatment retention and successful weight loss. Generalized linear mixed models were used to evaluate the relationships between factors and obesity‐related outcomes, with rurality differences assessed through interaction terms.ResultsPatient characteristics associated with increased odds of initiating CLMI included female sex (p < 0.001), black race (p < 0.001), sleep apnea (p < 0.001), mood disorder (p < 0.001), and use of medications associated with weight loss (p < 0.001) or weight gain (p < 0.001). Facility use of telehealth was associated with greater odds of CLMI initiation in urban Veterans (p < 0.001) but lower retention in both populations (p = 0.003). Routine consideration of pharmacotherapy was associated with higher CLMI initiation. Environmental characteristics associated with increased odds of CLMI initiation included percent of population foreign born (OR = 1.03 per 10% increase; p < 0.001), percent black (p < 0.001), and high walkability index (p < 0.001). The relationship between total population and CLMI initiation differed by rurality, as greater population was associated with lower odds of CLMI initiation in urban areas (OR: 0.99 per 1000 population; p < 0.001), but higher odds in rural areas (OR:1.01, p = 0.01). Veterans in the south were less likely to initiate CLMI and had lower retention (p < 0.001).ConclusionTreatment and retention of CLMI among Veterans remain low, highlighting areas for improvement to expand its reach both urban and rural Veterans.

AbstractPurposeTo assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA).MethodsAn Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process‐oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same‐day access; continuity with primary care provider; and postdischarge follow‐up. Qualitative data collected during on‐site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics.FindingsAfter adjusting for patient‐ and practice‐level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow‐up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high‐speed Internet were also reported as barriers.ConclusionsThis study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient‐centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context.

Background Sex‐specific effectiveness of rivaroxaban ( RIVA ), dabigatran ( DABI ), and warfarin in reducing myocardial infarction ( MI ), heart failure ( HF ), and all‐cause mortality among patients with atrial fibrillation are not known. We assessed sex‐specific associations of RIVA , DABI , or warfarin use with the risk of MI , HF , and all‐cause mortality among patients with atrial fibrillation. Methods and Results Medicare beneficiaries (men: 65 734 [44.8%], women: 81 135 [55.2%]) with atrial fibrillation who initiated oral anticoagulants formed the study cohort. Inpatient admissions for MI , HF , and all‐cause mortality were compared between the 3 drugs separately for men and women using 3‐way propensity‐matched samples. In men, RIVA use was associated with a reduced risk of MI admissions compared with warfarin use (hazard ratio [95% confidence interval ( CI ): 0.59 [0.38–0.91]), with a trend towards reduced risk compared with DABI use (0.67 [0.44–1.01]). In women, there were no significant differences in the risk of MI admissions across all 3 anticoagulants. In both sexes, RIVA use and DABI use were associated with reduced risk of HF admissions (men: RIVA ; 0.75 [0.63–0.89], DABI ; 0.81 [0.69–0.96]) (women: RIVA ; 0.64 [0.56–0.74], DABI ; 0.73 [0.63–0.83]) and all‐cause mortality (men: RIVA ; 0.66 [0.53–0.81], DABI ; 0.75 [0.61–0.93]) (women: RIVA ; 0.76 [0.63–0.91], DABI ; 0.77 [0.64–0.93]) compared with warfarin use. Conclusions RIVA use and DABI use when compared with warfarin use was associated with a reduced risk of HF admissions and all‐cause mortality in both sexes. However, reduced risk of MI admissions noted with RIVA use appears to be limited to men.