Bradley Vincent Watts

Purpose: The United States faces a looming nationwide shortage of healthcare workers, especially in rural areas. This is particularly concerning for the Veterans Health Administration (VHA), the US’ largest integrated healthcare system, which is experiencing high vacancy rates. Professional training programs can increase recruitment and retention in rural areas. We examined the 22 Advanced Fellowships offered by the VHA's Office of Academic Affiliations to assess their potential for retaining trainees in rural areas and at the VA. Methods: Fellow surveys were administered from June 2018 through August 2023 in this cross‐sectional study. Key variables included fellowship characteristics (location, topic area, length), and post‐fellowship employment, including location (rural or non‐rural), and type (clinical or non‐clinical, VA or non‐VA). We followed STROBE guidelines in reporting. Findings: Six (13%) of the 47 training sites are at facilities serving primarily rural veteran populations; six of the 22 programs are offered at these sites. Of the 843 fellows trained during the study period, 55 (7%) were at rural‐serving VAMCs. Fellows who trained in rural‐serving areas versus non‐rural areas were significantly more likely to be employed in rural areas post‐fellowship (63% vs. 2%, p < 0.01), and tended to remain employed at or affiliated with the VA post‐fellowship at higher rates. Conclusions: The Advanced Fellowship program is effective at retaining trainees in rural areas and should be considered as part of the VA's strategy to address rural workforce shortages. Additional research is needed to assess longitudinal retention and the potential for targeted program expansion in rural sites.

Background: Despite nursing being the largest US health profession, only 16% of registered nurses (RNs) practice in rural areas, where health care access is limited. This significantly impacts rural residents, including over 2.7 million rural veterans receiving care at the Veterans Health Administration, leading to compromised health outcomes. Nurses are vital in primary care, improving coordination and management of chronic conditions. Objectives: Identify recruitment and retention programs for rural nurses (licensed vocational nurses/licensed practical nurses and RNs), including strategy characteristics and location. Research Design: We conducted a scoping review of published and gray literature. Eligible studies targeted US rural nurse recruitment and retention strategies. Measures: Data were extracted for program characteristics, including strategy type (eg, financial incentive), focus (recruitment, retention, or both), and collaboration levels (single or multi-institutional). Results: Of 1179 unique articles identified, only 60 met the inclusion criteria. An additional 42 programs were identified from gray literature, totaling 102 programs. Twenty-two programs used a multipronged approach (2–14 strategies), totaling 180 strategies. Education (n=85) and personal and professional support (n=54) were the most frequently used recruitment and retention strategies. Conclusions: Of the 102 programs, only 22 used a multipronged approach, with education as the most frequently used strategy. More programs should use a multipronged approach and provide additional incentives and support (eg, financial incentives) to rural nurses beyond education. Only 4 strategies were regulatory, shedding light on the need for more nurse recruitment and retention support at the policy level.

Background: There has been a proliferation of health professions training programmes focused on quality and patient safety, but little information regarding the outcomes of these programmes. The purpose of this study was to examine the impact of an interprofessional quality and patient safety curriculum on career outcomes of interprofessional healthcare learners for the Veterans Affairs Patient Safety Fellowship. Method: We conducted a survey-based assessment of 117 alumni of the Interprofessional Fellowship in Patient Safety assessing their satisfaction with the training program and career impacts. Results: 84 of 117 alumni were located and participated in the assessment. Fellows entered the training programme from a wide range of educational experiences, but most were in their early career at entry. Satisfaction with the training programme was high, with 42% (n=35) of alumni reporting being extremely satisfied with their fellowship experience. Programme alumni reported being either extremely or very knowledgeable about quality and patient safety (77%, n=65). Fellows reported considerable engagement with the academic field of patient safety and quality, with 63% (n=53) having published at least one manuscript about the topic and 75% (n=63) reporting a role teaching patient safety and quality improvement. Fellows’ employments post training were quite varied, although positions focused on health profession education were most common. Conclusions: The Interprofessional Fellowship in Patient Safety is an early successful example of an interprofessional training programme that resulted in satisfied alumni who reported good knowledge and abilities in the topic of patient safety. Career pathways were varied, but a focus on health professions education post fellowship was prominent.

There is a continued need to improve the quality of health care services and the health outcomes associated with that care. Quality improvement model and the Learning Health System framework have emerged as potential methods to achieve the goals of better care and enhanced outcomes. Few practical tools and approaches have been developed to assist with the initiation of quality improvement and development of a Learning Health System. The Department of Veterans Affairs developed and deployed a national system to assist and organize improvement projects and serve as a database for learning. During its first 5 years of use, 7397 quality improvement projects were completed using the electronic tool. National implementation of a structured tool for quality improvement is possible.

Patients diagnosed with attention-deficit hyperactivity disorder (ADHD) are at an elevated risk for suicide. No prior work has assessed the association between stimulant prescriptions and death by suicide in this population. This retrospective cohort study included Department of Veterans Affairs patients with an active ADHD diagnosis that received stimulant medications between 2016 and 2019. We found that months with active stimulant medication prescription was associated with decreased risk of suicide mortality compared with months without stimulant medication (odds ratio 0.57, 95% CI 0.36–0.88). Our results suggest that prescribing stimulant medications for patients diagnosed with ADHD is associated with decreased risk of suicide mortality.

Summary: Controversy exists regarding the efficacy of lithium for suicide prevention. Except for a recent trial that enrolled over 500 patients, available trials of lithium for suicide prevention have involved small samples. It is challenging to measure suicide in a single randomised controlled trial (RCT). Adding a single large study to existing meta-analyses may provide insights into lithium's anti-suicidal effects. We performed a meta-analysis of RCTs comparing lithium with a control condition for suicide prevention. MEDLINE and other databases were searched up to 30 November 2021. Efficacy was assessed by calculating the summary Peto odds ratio (OR) and incidence rate ratio (IRR) with 95% confidence intervals. Among seven RCTs, the odds of suicide were lower among patients receiving lithium versus control (OR = 0.30, 95% CI 0.09–1.02; IRR = 0.22, 95% CI 0.05–1.05), although the findings were still not statistically significant. The role of lithium in suicide prevention remains uncertain.

Background: There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality.Aims: This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality.Method: Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n= 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository.Results: Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37–0.88).Conclusions: Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.

It is unclear if a course of electroconvulsive therapy (ECT) is associated with a decreased risk of death by suicide. This study examined the association of adequate exposure to ECT with risk of death by suicide in a present-day sample.

Background: Irregular hospital discharge is highly prevalent among people admitted to hospital for mental health reasons. No study has examined the relationship between irregular discharge, post-discharge mortality and treatment setting (i.e. mortality after patients are discharged from acute in-patient or residential mental health settings). Aims: To understand the relationship between irregular discharge and mortality among patients discharged from acute in-patient and residential settings. Method: A retrospective study was conducted in members of the US veteran population discharged from acute in-patient or residential settings of the US Department of Veterans Affairs between 2003 and 2018. Multivariate Cox proportional hazards were used to evaluate associations between irregular discharge and suicide, external-cause (as defined by ICD-10 Codes: V01-Y98) and all-cause mortality in the first 30-, 90- and 180-days post-discharge. Results: There were over 1.5 million mental health discharges between 2003 and 2018. Patients with an irregular discharge were at increased risk for suicide, external-cause and all-cause mortality in the first 180 days after discharge. In the first 30 days after discharge, patients with irregular discharge had more than three times greater suicide risk than patients with regular discharge (adjusted hazard ratio (HR) = 3.41, 95% CI 2.21–5.25). Suicide risk was higher among patients with irregular discharge in the first 30 days after acute in-patient discharge (adjusted HR = 1.55, 95% CI 1.11–2.16). In both settings, the mortality risk associated with irregular discharge attenuated but remained elevated within 90 and 180 days. Conclusions: Irregular discharge after an acute in-patient or residential stay poses a large risk for mortality soon after discharge. Clinicians must identify effective interventions to mitigate harms associated with irregular discharge in these settings.