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Background Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA) has been a frontrunner in the use of nurse practitioners (NPs) and physician assistants (PAs). Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians. Methods This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician). Results NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits. Conclusions This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.

Background: Approximately 697,000 members of the U.S. Armed Forces were deployed to the Persian Gulf in support of the 1990–1991 Persian Gulf War (GW). Subsequently, many deployed and some non-deployed veterans developed a chronic multi-symptom illness, now named Gulf War Illness (GWI). This manuscript outlines the methods and rationale for studying the genomics of GWI within the Million Veteran Program (MVP), a VA-based national research program that has linked medical records, surveys, and genomic data, enabling genome-wide association studies (GWASs). Methods: MVP participants who served in the military during the GW era were contacted by mail and invited to participate in the GWI study. A structured health questionnaire, based on a previously tested instrument, was also included in the mailing. Data on deployment locations and exposures, symptoms associated with GWI, clinical diagnoses, personal habits, and health care utilization were collected. Self-reported data will be augmented with chart reviews and structured international classification of disease codes, to classify participants by GWI case status. We will develop a phenotyping algorithm, based on two commonly used case definitions, to determine GWI status, and then conduct a nested case-control GWAS. Genetic variants associated with GWI will be investigated, and gene–gene and gene–environment interactions studied. The genetic overlap of GWI with, and causative mechanisms linking this illness to, other health conditions and the effects of genomic regulatory mechanisms on GWI risk will also be explored. Conclusions: The proposed initial GWAS described in this report will investigate the genomic underpinnings of GWI with a large sample size and state-of-the-art genomic analyses and phenotyping. The data generated will provide a rich and expansive foundation on which to build additional analyses.

Maternal stress is a risk factor for adverse pregnancy outcomes (APOs). This study evaluates the associations of prenatal stress and APOs with maternal stress years after pregnancy. The 10-item Perceived Stress Scale (PSS) (0–40 range) was completed in the first and third trimesters, and 2–7 years after delivery among a subsample (n = 4161) of nulliparous women enrolled at eight US medical centers between 2010 and 2013 in a prospective, observational cohort study. Demographics, medical history, and presence of APOs (gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preeclampsia (PE), and medically indicated or spontaneous preterm birth (miPTB, sPTB)) were obtained. The associations of prenatal PSS and the presence of APOs with PSS scores years after delivery were estimated using multivariable linear regression. Mean PSS scores were 12.5 (95% CI 12.3, 12.7) and 11.3 (95% CI 11.1, 11.5) in the first and third trimesters respectively and 14.9 (95% CI 14.7, 15.1) 2–7 years later, an average increase of 2.4 points (95% CI 2.2, 2.6) from the start of pregnancy. Regressing PSS scores after delivery on first-trimester PSS and PSS increase through pregnancy showed positive associations, with coefficients (95% CI) of 2.8 (2.7, 3.0) and 1.5 (1.3, 1.7) per 5-point change, respectively. Adding APO indicator variables separately showed higher PSS scores for women with HDP (0.7 [0.1, 1.3]), PE (1.3 [0.6, 2.1]), and miPTB (1.3 [0.2, 2.4]), but not those with GDM or sPTB. In this geographically and demographically diverse sample, prenatal stress and some APOs were positively associated with stress levels 2–7 years after pregnancy.ClinicalTrials.gov Registration number NCT02231398.

ABSTRACT Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Objectives: We evaluated relapse patterns after transoral laser microsurgery (TLM) in squamous cell carcinoma (SCC) of the tonsil and tongue base and evaluated the indications for adjuvant irradiation. Methods: Between December 1, 1996, and December 31, 2005, 79 patients with previously untreated SCC of the tonsil or tongue base underwent TLM with or without neck dissection. Thirty-eight patients (48%) underwent postoperative irradiation (median, 62 Gy) to the primary site and the neck. Analysis of relapse patterns was performed on the basis of adverse risk factors and the presence or absence of adjuvant irradiation. Results: The median follow-up for living patients was 47 months (range, 10 to 107 months), and patients were monitored for at least 2 years or until recurrence or death. Local, regional, and distant treatment failures numbered 4, 6, and 4 for surgery alone (n = 41) and 0, 2, and 6 for adjuvant irradiation (n = 38), respectively. Patients with high-risk features (extracapsular extension or at least 2 adverse factors) had locoregional control rates at 2 or more years of 66% and 94% for TLM alone and TLM plus adjuvant irradiation, respectively. Conclusions: Adjuvant irradiation after TLM resection of oropharyngeal SCC with intermediate- or high-risk features improves locoregional control compared with TLM alone.

Over the past two decades, 12 large epidemiologic studies and 2 registries have focused on U.S. veterans of the 1990–1991 Gulf War Era. We conducted a review of these studies’ research tools to identify existing gaps and overlaps of efforts to date, and to advance development of the next generation of Gulf War Era survey tools. Overall, we found that many of the studies used similar instruments. Questions regarding exposures were more similar across studies than other domains, while neurocognitive and psychological tools were the most variable. Many studies focused on self-reported survey results, with a range of validation practices. However, physical exams, biomedical assessments, and specimen storage were not common. This review suggests that while research may be able to pool data from past surveys, future surveys need to consider how their design can yield data comparable with previous surveys. Additionally, data that incorporate recent technologies in specimen and genetic analyses would greatly enhance such survey data. When combined with existing data on deployment-related exposures and post-deployment health conditions, longitudinal follow-up of existing studies within this collaborative framework could represent an important step toward improving the health of veterans.

Objective. Prior studies of full-marathon participants have demonstrated a higher incidence of hyponatraemia in runners with completion times of 4 hours or more. Our primary aim was to determine if slower pace is associated with increased prevalence of hyponatraemia. Secondly, we evaluated the prevalence of hyponatraemia in full-marathoners v. halfmarathoners.Methods. This observational, cross-sectional study comprised consenting runners in the 26.2 With Donna, The National Marathon to Finish Breast Cancer, in Jacksonville Beach, Florida, February 2008. On race day, participants completed a questionnaire, provided finger-stick blood samples, and were weighed both pre- and post-race.Results. A significant negative association was found between pace and post-race sodium level (p<0.001). A negative correlation was found between finishing time and post-race sodium level (p<0.001). The prevalence of post-race hyponatraemia was 4% (4/106) among half-marathoners and 13% (12/89) among full-marathoners (P=0.02). An inverse correlation was found between sodium change and weight change, significant in fullmarathoners (r=-0.55, p<0.001) but not half-marathoners (r=- 0.23, p=0.042).Conclusions. Slower race pace and longer finishing times were associated with lower post-race sodium levels. Full-marathoners had a significantly higher prevalence of hyponatraemia. The development of hyponatraemia was associated with weight gain. Our data indicate that the relationship between post-race sodium concentration and pace differs according to the distance of the event. We can extrapolate from this data that longer racedistance with increased availability of fluid stations combined with a slower pace may increase the risk of developing exerciseinduced hyponatraemia.

Objective. Prior studies of full-marathon participants have demonstrated a higher incidence of hyponatraemia in runners with completion times of 4 hours or more. Our primary aim was to determine if slower pace is associated with increased prevalence of hyponatraemia. Secondly, we evaluated the prevalence of hyponatraemia in full-marathoners v. half-marathoners. Methods. This observational, cross-sectional study comprised consenting runners in the 26.2 With Donna, The National Marathon to Finish Breast Cancer, in Jacksonville Beach, Florida, February 2008. On race day, participants completed a questionnaire, provided finger-stick blood samples, and were weighed both pre- and post-race. Results. A significant negative association was found between pace and post-race sodium level (p<0.001). A negative correlation was found between finishing time and post-race sodium level (p<0.001). The prevalence of post-race hyponatraemia was 4% (4/106) among half-marathoners and 13% (12/89) among full-marathoners (P=0.02). An inverse correlation was found between sodium change and weight change, significant in full-marathoners (r=-0.55, p<0.001) but not half-marathoners (r=-0.23, p=0.042). Conclusions. Slower race pace and longer finishing times were associated with lower post-race sodium levels. Full-marathoners had a significantly higher prevalence of hyponatraemia. The development of hyponatraemia was associated with weight gain. Our data indicate that the relationship between post-race sodium concentration and pace differs according to the distance of the event. We can extrapolate from this data that longer race distance with increased availability of fluid stations combined with a slower pace may increase the risk of developing exercise-induced hyponatraemia.

While externalizing behaviors are common among children with autism spectrum disorder (ASD), there is a shortage of specialist community-based clinicians to provide treatment. Parent–Child Interaction Therapy (PCIT), an intervention designed to reduce child disruptive behaviors, may be effective for families of children with ASD but has rarely been studied outside of university-based research settings. We examined the effectiveness of PCIT delivered for children with (N = 109) and without (N = 2,324) ASD/developmental delays (DD) across community-based agencies in Oregon. Findings revealed significant reductions in disruptive behavior and positive changes in the parent-child relationship in both groups. These findings support PCIT as an efficacious intervention for children with ASD/DD and demonstrate PCIT’s promise in community-based agencies with non-specialized clinicians.