The Epilepsy Centers of Excellence at the Veterans Health Administration.

Introduction: The Veterans Health Administration (VHA) Epilepsy Centers of Excellence (ECoE) was established in 2008 to provide specialized care for veterans with epilepsy. Although established more than a decade ago, there has been no systematic evaluation of the ECoE's performance in key mission areas. We evaluated their performance in several key mission areas-clinical care, research, education, and outreach-since inception to evaluate their success in meeting the initial mandate.

Multiple sclerosis disease-modifying therapy use in the department of veteran affairs and Medicare: A comparative analysis.

Background: High-cost disease-modifying therapies (DMT) for multiple sclerosis (MS) have created affordability challenges for people with MS (PwMS) and payers. The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the US and uses a variety of approaches to manage utilization and cost of MS DMT. The objective of this paper is to compare national utilization trends in the VA to the US Medicare program, another large federal public healthcare program.

Open Burn Pit Exposure in Headache Disorder and Migraine.

Importance: Open burn pits have commonly been used for waste disposal by the US military but have not been systematically investigated as an independent risk factor for headache disorders.

Objective: To evaluate the association between exposure to open burn pits and incidence of headache and migraine.

Design, Setting, And Participants: This retrospective cohort study used data from the Veterans Health Administration Headache Cohort along with data from the US Department of Defense and the Airborne Hazards and Open Burn Pit (AH&OBP) Registry to assess registry participants with potential exposure to open burn pits in the Veterans Health Administration from April 1, 2014, through October 31, 2022.

Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis.

Objective: To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020).

Background: Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown.

Methods: This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program.

Objectives: Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program.

Background: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.

Evaluating Screening Tests for Depression in Post-Stroke Older Adults.

Background: Uncertainty surrounds which screening test to use in older patients with poststroke depression, in whom symptoms of depression are more complex and often occur in conjunction with other comorbidities. We evaluated screening tests for depression among a cohort of older ambulatory individuals with comorbid ischemic heart disease and prior stroke.

Methods: We administered 4 depression screening instruments to 148 participants with ischemic heart disease and self-reported stroke from The Heart and Soul Study.

Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis.

Introduction: Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems.

Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke.

Importance: The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes.

Objective: To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide.

OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach.

Background: OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established.

Objective: To define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures.

A systematic review of the effects of modifiable risk factor interventions on the progression of multiple sclerosis.

Background: Several risk factors are associated with multiple sclerosis (MS) progression and may be amenable to intervention.

Objective: To systematically review the evidence for interventions targeting risk factors for MS progression.

Methods: We searched six databases and existing reviews till March 2015 and consulted with experts to identify randomized controlled trials (RCTs) of interventions targeting MS risk factors (PROSPERO 2015:CRD42015016461).

A systematic review of modifiable risk factors in the progression of multiple sclerosis.

Background: The presenting symptoms and rate of progression of multiple sclerosis (MS) are very heterogeneous. The diverse clinical manifestations and the clinical course of the disease may vary with modifiable risk factors.

Objective: To systematically review modifiable risk factors and exposures associated with MS progression.

OnabotulinumtoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From a Delphi Panel Process.

Background: OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures.

Objective: To define treatment paradigms for PSS upper-limb common postures.

Caregiver burden, productivity loss, and indirect costs associated with caring for patients with poststroke spasticity.

Objective: Many stroke survivors experience poststroke spasticity and the related inability to perform basic activities, which necessitates patient management and treatment, and exerts a considerable burden on the informal caregiver. The current study aims to estimate burden, productivity loss, and indirect costs for caregivers of stroke survivors with spasticity.

Methods: Internet survey data were collected from 153 caregivers of stroke survivors with spasticity including caregiving time and difficulty (Oberst Caregiver Burden Scale), Work Productivity and Activity Impairment measures, and caregiver and patient characteristics.

Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities.

Care coordination between the specialty care provider (SCP) and the primary care provider (PCP) is a critical component of safe, efficient, and patient-centered care. Veterans Health Administration conducted a series of focus groups of providers, from specialty care and primary care clinics at VA Medical Centers nationally, to assess 1) what SCPs and PCPs perceive to be current practices that enable or hinder effective care coordination with one another and 2) how these perceptions differ between the two groups of providers. A qualitative thematic analysis of the gathered data validates previous studies that identify communication as being an important enabler of coordination, and uncovers relationship building between specialty care and primary care (particularly through both formal and informal relationship-building opportunities such as collaborative seminars and shared lunch space, respectively) to be the most notable facilitator of effective communication between the two sides.

Adherence associated with oral medications in the treatment of spasticity.

Objective: To examine adherence to baclofen, tizanidine, and dantrolene (U.S. Food and Drug Administration-approved oral spasticity medications), and identified determinants of adherence.

Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity.

Objective: To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

Design: Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

Setting: Internet-based survey.

Secondary stroke prevention: from guidelines to clinical practice.

Stroke remains a leading cause of mortality and is associated with substantial morbidity in the United States. The majority of strokes are of ischemic origin, with an atherothrombotic trigger, and the clinical manifestation of atherothrombosis depends on the affected vascular site. The systemic nature of atherosclerosis means that stroke patients are at increased risk of ischemic events in several vascular beds, including cerebral, coronary and peripheral sites.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary.

Background: A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

Methods: Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

Role of antiplatelet therapy in cardiovascular disease II: Ischemic stroke.

The etiology of cerebrovascular disease is heterogeneous, with the majority of strokes being of ischemic origin. Transient ischemic attack is now considered to be an important precursor and long-term risk factor for ischemic stroke. Given the lack of acute therapies for ischemic stroke, current treatments focus on secondary prevention through risk-factor management, pharmacotherapy and interventional approaches.

Tissue plasminogen activator for acute ischemic stroke in clinical practice: a meta-analysis of safety data.

Background And Purpose: Concerns persist regarding the safety of tissue plasminogen activator (tPA) therapy for acute ischemic stroke. Numerous case series of clinical experience with tPA have been published that provide additional data on the safety of thrombolytic therapy.

Methods: This is a meta-analysis of 15 published, open-label studies that broadly followed approved indications and guidelines for tPA use in nonselective patient populations.