Tag: pubmed

J Med Internet Res. 2024 Aug 26;26:e54034. doi: 10.2196/54034.

ABSTRACT

BACKGROUND: Social media platforms are increasingly used to recruit patients for clinical studies. Yet, patients’ attitudes regarding social media recruitment are underexplored.

OBJECTIVE: This mixed methods study aims to assess predictors of the acceptance of social media recruitment among patients with hepatitis B, a patient population that is considered particularly vulnerable in this context.

METHODS: Using a mixed methods approach, the hypotheses for our survey were developed based on a qualitative interview study with 6 patients with hepatitis B and 30 multidisciplinary experts. Thematic analysis was applied to qualitative interview analysis. For the cross-sectional survey, we additionally recruited 195 patients with hepatitis B from 3 clinical centers in Germany. Adult patients capable of judgment with a hepatitis B diagnosis who understood German and visited 1 of the 3 study centers during the data collection period were eligible to participate. Data analysis was conducted using SPSS (version 28; IBM Corp), including descriptive statistics and regression analysis.

RESULTS: On the basis of the qualitative interview analysis, we hypothesized that 6 factors were associated with acceptance of social media recruitment: using social media in the context of hepatitis B (hypothesis 1), digital literacy (hypothesis 2), interest in clinical studies (hypothesis 3), trust in nonmedical (hypothesis 4a) and medical (hypothesis 4b) information sources, perceiving the hepatitis B diagnosis as a secret (hypothesis 5a), attitudes toward data privacy in the social media context (hypothesis 5b), and perceived stigma (hypothesis 6). Regression analysis revealed that the higher the social media use for hepatitis B (hypothesis 1), the higher the interest in clinical studies (hypothesis 3), the more trust in nonmedical information sources (hypothesis 4a), and the less secrecy around a hepatitis B diagnosis (hypothesis 5a), the higher the acceptance of social media as a recruitment tool for clinical hepatitis B studies.

CONCLUSIONS: This mixed methods study provides the first quantitative insights into social media acceptance for clinical study recruitment among patients with hepatitis B. The study was limited to patients with hepatitis B in Germany but sets out to be a reference point for future studies assessing the attitudes toward and acceptance of social media recruitment for clinical studies. Such empirical inquiries can facilitate the work of researchers designing clinical studies as well as ethics review boards in balancing the risks and benefits of social media recruitment in a context-specific manner.

PMID:39186322 | DOI:10.2196/54034

Aging Ment Health. 2024 Aug 26:1-8. doi: 10.1080/13607863.2024.2394591. Online ahead of print.

ABSTRACT

OBJECTIVES: Various dementia risk scores exist that assess different factors. We investigated the association between the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score and modifiable risk factors in the Lifestyle for Brain Health (LIBRA) score in a German population at high risk of Alzheimer’s disease.

METHOD: Baseline data of 807 participants of AgeWell.de (mean age: 68.8 years (SD = 4.9)) were analysed. Stepwise multivariable regression was used to examine the association between the CAIDE score and additional risk factors of the LIBRA score. Additionally, we examined the association between dementia risk models and cognitive performance, as measured by the Montreal Cognitive Assessment.

RESULTS: High cognitive activity (β = -0.016, p < 0.001) and high fruit and vegetable intake (β = -0.032, p < 0.001) correlated with lower CAIDE scores, while diabetes was associated with higher CAIDE scores (β = 0.191; p = 0.032). Although all were classified as high risk on CAIDE, 31.5% scored ≤0 points on LIBRA, indicating a lower risk of dementia. Higher CAIDE and LIBRA scores were associated with lower cognitive performance.

CONCLUSION: Regular cognitive activities and increased fruit and vegetable intake were associated with lower CAIDE scores. Different participants are classified as being at-risk based on the dementia risk score used.

PMID:39186318 | DOI:10.1080/13607863.2024.2394591

JAMA Netw Open. 2024 Aug 1;7(8):e2427441. doi: 10.1001/jamanetworkopen.2024.27441.

ABSTRACT

IMPORTANCE: Few studies have investigated whether the associations between pregnancy-related factors and breast cancer (BC) risk differ by underlying BC susceptibility. Evidence regarding variation in BC risk is critical to understanding BC causes and for developing effective risk-based screening guidelines.

OBJECTIVE: To examine the association between pregnancy-related factors and BC risk, including modification by a of BC where scores are based on age and BC family history.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included participants from the prospective Family Study Cohort (ProF-SC), which includes the 6 sites of the Breast Cancer Family Registry (US, Canada, and Australia) and the Kathleen Cuningham Foundation Consortium (Australia). Analyses were performed in a cohort of women enrolled from 1992 to 2011 without any personal history of BC who were followed up through 2017 with a median (range) follow-up of 10 (1-23) years. Data were analyzed from March 1992 to March 2017.

EXPOSURES: Parity, number of full-term pregnancies (FTP), age at first FTP, years since last FTP, and breastfeeding.

MAIN OUTCOMES AND MEASURES: BC diagnoses were obtained through self-report or report by a first-degree relative and confirmed through pathology and data linkages. Cox proportional hazards regression models estimated hazard ratios (HR) and 95% CIs for each exposure, examining modification by PARS of BC. Differences were assessed by estrogen receptor (ER) subtype.

RESULTS: The study included 17 274 women (mean [SD] age, 46.7 [15.1] years; 791 African American or Black participants [4.6%], 1399 Hispanic or Latinx participants [8.2%], and 13 790 White participants [80.7%]) with 943 prospectively ascertained BC cases. Compared with nulliparous women, BC risk was higher after a recent pregnancy for those women with higher PARS (last FTP 0-5 years HR for interaction, 1.53; 95% CI, 1.13-2.07; P for interaction < .001). Associations between other exposures were limited to ER-negative disease. ER-negative BC was positively associated with increasing PARS and increasing years since last FTP (P for interaction < .001) with higher risk for recent pregnancy vs nulliparous women (last FTP 0-5 years HR for interaction, 1.54; 95% CI, 1.03-2.31). ER-negative BC was positively associated with increasing PARS and being aged 20 years or older vs less than 20 years at first FTP (P for interaction = .002) and inversely associated with multiparity vs nulliparity (P for interaction = .01).

CONCLUSIONS AND RELEVANCE: In this cohort study of women with no prior BC diagnoses, associations between pregnancy-related factors and BC risk were modified by PARS, with greater associations observed for ER-negative BC.

PMID:39186276 | DOI:10.1001/jamanetworkopen.2024.27441

JAMA Netw Open. 2024 Aug 1;7(8):e2428975. doi: 10.1001/jamanetworkopen.2024.28975.

ABSTRACT

IMPORTANCE: Online symptom monitoring through patient-reported outcomes can enhance health-related quality of life and survival. However, widespread adoption in clinical care remains limited due to various barriers including the need to reduce health care practitioners’ workload.

OBJECTIVE: To report the effects of patient-reported outcome (PRO) symptom monitoring on HRQOL and survival up to 1 year after initiation of any treatment in patients with lung cancer.

DESIGN, SETTING, AND PARTICIPANTS: SYMPRO-Lung is a multicenter stepped-wedge cluster randomized trial including patients with stage I to IV lung cancer. The inclusion period was from October 24, 2019, until September 16, 2021, and data collection ended October 8, 2022. Data analysis was conducted from November 9, 2023, until March 18, 2024.

INTERVENTION: Patients in the intervention group reported PRO symptoms weekly using the Patient Reported Outcomes version of the Common Toxicity Criteria for Adverse Events lung cancer subset. If symptoms exceeded a validated threshold, an alert was sent to the health care practitioner (active intervention subgroup) or to the patient (reactive intervention subgroup). Patients in the control group received standard care.

MAIN OUTCOMES AND MEASURES: Health-related quality of life was measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire at baseline, 15 weeks (T1), 6 months (T2), and 1 year (T3), with the summary score (SS) and physical functioning (PF) as primary end points. Linear mixed-effects modeling was used to assess mean differences over time. Effect size (ES) of 0.40 or greater was considered clinically relevant. Cox proportional hazards regression survival analyses were performed to estimate the effect of the intervention on progression-free survival and overall survival (OS). Data were analyzed on an intention-to-treat basis.

RESULTS: A total of 515 patients (266 [51.7%] men; mean [SD] age, 65.4 [9.4] years) were included in the study (266 in the control group; 249 in the pooled intervention group). Most baseline characteristics were balanced between groups; however, the most notable exception was the distribution in cancer staging: the intervention group had a higher proportion of patients with stage IV cancer compared with the control group (139 [56%] vs 118 [44%]). The pooled intervention group had a significantly better SS (mean difference T1, 5.22; 95% CI, 2.72-7.73; P < .001; ES = 0.33; mean difference T2, 6.28; 95% CI, 3.65-8.92; P < .001; ES = 0.40; mean difference T3, 3.97; 95% CI, 1.15-6.80; P = .006; ES = 0.25) compared with the control group. Group differences improved more in PF but did not meet the ES greater than or equal to 0.40 threshold (mean difference T1, 7.00; 95% CI, 3.65-10.35; P < .001; ES = 0.27; mean difference T2, 6.79; 95% CI, 3.26-10.31; P < .001; ES = 0.26; mean difference T3, 5.01; 95% CI, 1.23-8.79; P = .009; ES = 0.19). No significant differences in HRQOL were observed between the reactive (n = 89) and active (n = 160) intervention groups. The HR for progression-free survival for the active intervention group compared with the control group was 0.78 (95% CI, 0.58-1.04); the finding was not statistically significant. The HR for overall survival for both interventions groups compared with the control group were not statistically significant.(active: HR, 0.80; 95% CI, 0.55-1.15; reactive: HR, 0.69; 95% CI, 0.42-1.15).

CONCLUSIONS AND RELEVANCE: In this 1-year follow-up of a stepped-wedge cluster randomized trial, PRO symptom monitoring yielded improvements in long-term HRQOL in patients with lung cancer. The reactive approach proved equally effective as the active approach. A nonsignificant potential survival benefit was observed for the intervention group. These positive results provide further evidence for the usefulness of routine PRO symptom monitoring in lung cancer care.

TRIAL REGISTRATION: The Netherlands trial register Identifier: NL7897.

PMID:39186274 | DOI:10.1001/jamanetworkopen.2024.28975

JAMA Netw Open. 2024 Aug 1;7(8):e2429661. doi: 10.1001/jamanetworkopen.2024.29661.

ABSTRACT

IMPORTANCE: The global refugee crisis disproportionately affects the Muslim world. Forced displacement often results in trauma-related mental health issues. Effective psychotherapy exists, but there are barriers to uptake by refugee groups as well as a lack of culturally appropriate interventions.

OBJECTIVE: To examine the efficacy of a brief, lay-led, mosque-based intervention, Islamic Trauma Healing (ITH), adapting empirically supported cognitive behavioral principles to improve mental health and well-being.

DESIGN, SETTING, AND PARTICIPANTS: In a randomized clinical trial, 101 participants received ITH or active assessment but delayed intervention (waiting list [WL]) in mosques and virtually in Seattle, Washington, and Columbus, Ohio, and were assessed through 12-week follow-up. Data were collected from July 14, 2018, through July 14, 2022, and data analysis was conducted from March 13 to July 31, 2023. United States-based refugees from Somalia who experienced a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Criterion A trauma exposure and posttraumatic stress disorder (PTSD) reexperiencing or avoidance. Analyses were intention-to-treat, using full information likelihood for missing data.

INTERVENTION: Islamic Trauma Healing included psychoeducation, discussion of the lives of prophets who had undergone trauma, and informal prayer turning to Allah about the trauma, incorporating cognitive restructuring and imaginal exposure. Lay-leader training is purposely brief: two 4-hour sessions with weekly supervision.

MAIN OUTCOMES AND MEASURES: The primary outcome was PTSD severity (measured with the Posttraumatic Diagnostic Scale for DSM-5 [PDS-5]). Secondary outcomes included depression (Patient Health Questionnaire-9), somatic symptoms (Somatic Symptoms Severity-8), and quality of well-being (World Health Organization Five Well-Being Index). Analyses were intention-to-treat.

RESULTS: Analyses were based on all 101 randomized participants (92 [91.1%] women; 9 [8.9%] men; mean [SD] age, 46.5 [12.02] years) with baseline mean (SD) PDS-5 score of 31.62 (16.55) points. There were significant differences in PTSD severity (d = -0.67), depression (d = -0.66), and well-being (d = 0.71), comparing ITH vs WL after the intervention. Gains were maintained through 12-week follow-up. Islamic Trauma Healing was consistent with religious and cultural practices (mean [SD], 3.8 [0.43]) and promoted community reconciliation (mean [SD], 3.8 [0.42]).

CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of a brief, lay-led mental health intervention, ITH proved superior to WL. The findings suggest that ITH has the potential to provide an easily trainable and scalable intervention, incorporating Islam and empirically supported principles, that addresses the psychological wounds of war and refugee trauma.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03502278.

PMID:39186273 | DOI:10.1001/jamanetworkopen.2024.29661

JAMA Netw Open. 2024 Aug 1;7(8):e2429696. doi: 10.1001/jamanetworkopen.2024.29696.

ABSTRACT

IMPORTANCE: Postelimination outbreaks threaten nearly a quarter century of measles elimination in the US. Understanding these dynamics is essential for maintaining the nation’s measles elimination status.

OBJECTIVE: To examine the demographic characteristics and transmission dynamics of the 2022 to 2023 central Ohio measles outbreak.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used electronic medical records and publicly available measles reports within an extensive central Ohio primary care network involving inpatient and outpatient settings. Participants included 90 children in Ohio with confirmed measles cases in 2022.

EXPOSURE: The exposure of interest was confirmed measles cases in Ohio in 2022. This included 5 internationally imported cases and 85 locally acquired cases.

MAIN OUTCOMES AND MEASURES: The primary outcome involved documenting and analyzing confirmed measles cases in Ohio in 2022, focusing on demographic characteristics, immunization status, and transmission links in outbreak-related cases.

RESULTS: This study analyzed 90 measles cases (47 [52.2%] male participants) in Ohio during 2022. Most participants self-identified as African or American Black (72 [80.0%]), with additional race categories including Asian, Hispanic, multirace (6 [6.7%]), White, and unknown (6 [6.7%]). Most participants were of Somali descent (64 [71.1%]), with additional ethnicity categories including American (16 [17.8%]), Guatemalan, Nepali, and unknown (6 [6.7%]). Participants were predominantly younger than 6 years (86 [95.5%]), unimmunized (89 [98.9%]), and resided in Franklin County, Ohio (83 [92.2%]). Prior to November 20, 2022, all cases occurred among unimmunized children of Somali descent in the Columbus area. Nosocomial superspreading events expanded the outbreak beyond the initially affected community.

CONCLUSIONS AND RELEVANCE: This cross-sectional study of measles cases in Ohio during 2022 found that the outbreak primarily affected unimmunized children of Somali descent, highlighting the necessity for culturally tailored public health strategies to maintain measles elimination in the US. These findings underscore the importance of implementing targeted interventions and enhancing community engagement to increase vaccination rates.

PMID:39186272 | DOI:10.1001/jamanetworkopen.2024.29696

JAMA Netw Open. 2024 Aug 1;7(8):e2429820. doi: 10.1001/jamanetworkopen.2024.29820.

ABSTRACT

IMPORTANCE: The optimal treatment of acute uncomplicated appendicitis in older adults with frailty is not defined.

OBJECTIVE: To examine outcomes associated with treatment strategies for acute uncomplicated appendicitis in older adults with or without frailty.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used National Inpatient Sample data from adults 65 years or older with a diagnosis of uncomplicated appendicitis from January 1, 2016, to December 31, 2018. Data were analyzed from July to November 2023. The National Inpatient Sample database approximates a 20% stratified sample of all inpatient hospital discharges in the US.

EXPOSURES: Study patients were categorized into 3 groups: nonoperative management, immediate operation, and delayed operation.

MAIN OUTCOMES AND MEASURES: Clinical outcomes, including hospital complications and in-hospital mortality, were assessed among older adults with and without frailty, identified using an adapted claims-based frailty index.

RESULTS: A total of 24 320 patients were identified (median [IQR] age, 72 [68-79] years; 50.9% female). Of those, 7290 (30.0%) were categorized as having frailty. Overall, in-hospital mortality was 1.4%, and the incidence of complications was 37.3%. In patients with frailty, multivariable analysis showed both nonoperative management (odds ratio [OR], 2.89; 95% CI, 1.40-5.98; P < .001) and delayed appendectomy (OR, 3.80; 95% CI, 1.72-8.43; P < .001) were associated with increased in-hospital mortality compared with immediate appendectomy. In patients without frailty, immediate appendectomy was associated with increased hospital complications compared with nonoperative management (OR, 0.77; 95% CI, 0.64-0.94; P = .009) and lower hospital complications compared with delayed appendectomy (OR, 2.05; 95% CI, 1.41-3.00; P < .001).

CONCLUSIONS AND RELEVANCE: In this cohort study of older adults with uncomplicated appendicitis, outcomes differed among management strategies based on frailty status. Routine frailty assessments incorporated in the care of older adult patients may help guide discussions for shared decision-making.

PMID:39186270 | DOI:10.1001/jamanetworkopen.2024.29820

JAMA Netw Open. 2024 Aug 1;7(8):e2429826. doi: 10.1001/jamanetworkopen.2024.29826.

ABSTRACT

IMPORTANCE: Extreme weather has major implications for state and national health care systems; however, statistics examining weather-related injuries and fatalities are limited.

OBJECTIVE: To examine the frequency and regional distribution of major disaster events (MDEs) in the US.

DESIGN, SETTING, AND PARTICIPANTS: This ecologic cross-sectional study of MDEs occurring between January 1, 2006, and December 31, 2021, evaluated US data on all injuries and fatalities included in the National Oceanic and Atmospheric Administration National Centers for Environmental Information Storm Events Database. The data analysis was performed between February 22, 2023, and April 1, 2024.

EXPOSURES: Major disaster events defined as an environmental event that caused either at least 50 injuries or at least 10 deaths.

MAIN OUTCOMES AND MEASURES: All MDEs were evaluated using descriptive statistics for event type, property damage, and rural or urban classification according to the National Centers for Health Statistics Urban-Rural Classification Scheme for Counties. The location of events according to Administration for Strategic Preparedness and Response (ASPR) region and hospital bed capacity of ASPR regions were also examined.

RESULTS: Between 2006 and 2021, 11 159 storm events caused 42 254 injuries and 9760 deaths. Major disaster events accounted for 209 weather events (1.9%) but caused 19 463 weather-associated injuries (46.1%) and 2189 weather-associated deaths (22.4%). The majority of MDEs were caused by extreme heat (86 [41.1%]) and tornadoes (67 [32.1%]). While a larger proportion of MDEs occurred in urban areas (151 [75.1%]) vs rural areas (50 [24.9%]), rural MDEs caused a median of 9 (IQR, 2-16) deaths per event vs 4 (IQR, 0-14) deaths per event in urban areas. The majority of MDEs occurred in either ASPR region 4 (51 [24.5%]) or region 9 (45 [21.6%]). Certain event types, such as fires, wind, and hurricanes or storms, were geographically concentrated, while extreme heat and floods affected regions across the US equally. Urban counties had disproportionately greater hospital bed capacity than rural counties relative to population and MDE distributions.

CONCLUSIONS AND RELEVANCE: The findings of this ecologic study indicate that while MDEs accounted for a small proportion of all weather events, they were associated with a disproportionate number of injuries and fatalities. Integrating these data into county, state, and regional hazard vulnerability analyses is crucial to ensuring preparedness and mitigating climate risk.

PMID:39186269 | DOI:10.1001/jamanetworkopen.2024.29826

JAMA Netw Open. 2024 Aug 1;7(8):e2430198. doi: 10.1001/jamanetworkopen.2024.30198.

ABSTRACT

IMPORTANCE: Robust longitudinal studies of within-child changes in mental health associated with the COVID-19 pandemic are lacking, as are studies examining sources of heterogeneity in such changes.

OBJECTIVE: To investigate within-child changes, overall and between subgroups, in youth mental health from prepandemic to midpandemic.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used longitudinal prepandemic and midpandemic data from the Environmental influences on Child Health Outcomes (ECHO) Program, collected between January 1, 2015, and March 12, 2020 (prepandemic), and between March 13, 2020, and August 31, 2022 (midpandemic). Data were analyzed between December 1, 2022, and June 1, 2024. The sample included 9 US-based observational longitudinal pediatric ECHO cohorts. Cohorts were included if they collected the Child Behavior Checklist (CBCL) School Age version before and during the pandemic on more than 20 participants of normal birth weight aged 6 to 17 years.

EXPOSURE: The COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES: Prepandemic to midpandemic changes in CBCL internalizing, externalizing, depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD) scores were estimated, and differences in outcome trajectories by child sociodemographic characteristics (age, sex, race, ethnicity, and poverty level) and prepandemic mental health problems were examined using established CBCL clinical score thresholds.

RESULTS: A total of 1229 participants (mean [SD] age during the pandemic, 10.68 [2.29] years; 625 girls [50.9%]) were included. The sample was socioeconomically diverse (197 of 1056 children [18.7%] lived at ≤130% of the Federal Poverty Level; 635 (51.7%) identified as White, 388 (31.6%) as Black, 147 (12.0%) as multiracial, 40 (3.3%) as another race, and 118 (9.6%) as Hispanic). Generalized linear mixed-effects models revealed minor decreases in externalizing problems (β = -0.88; 95% CI, -1.16 to -0.60), anxiety (β = -0.18; 95% CI, -0.31 to -0.05), and ADHD (β = -0.36; 95% CI, -0.50 to -0.22), but a minor increase in depression (β = 0.22; 95% CI, 0.10 to 0.35). Youth with borderline or clinically meaningful prepandemic scores experienced decreases across all outcomes, particularly externalizing problems (borderline, β = -2.85; 95% CI, -3.92 to -1.78; clinical, β = -4.88; 95% CI, -5.84 to -3.92). Low-income (β = -0.76; 95% CI, -1.14 to -0.37) and Black (β = -0.52; 95% CI, -0.83 to -0.20) youth experienced small decreases in ADHD compared with higher income and White youth, respectively.

CONCLUSIONS AND RELEVANCE: In this longitudinal cohort study of economically and racially diverse US youth, there was evidence of differential susceptibility and resilience for mental health problems during the pandemic that was associated with prepandemic mental health and sociodemographic characteristics.

PMID:39186267 | DOI:10.1001/jamanetworkopen.2024.30198

JAMA Netw Open. 2024 Aug 1;7(8):e2430205. doi: 10.1001/jamanetworkopen.2024.30205.

ABSTRACT

IMPORTANCE: Department of Veterans Affairs (VA) health care spending has increased in the past decade, in part due to legislative changes that expanded access to VA-purchased care.

OBJECTIVE: To understand how insurance coverage and enrollment in VA has changed between 2010 and 2021.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from surveys conducted from 2010 to 2021. Participants were respondents across 4 national surveys who reported being a US veteran and reported on health insurance enrollment. Data were analyzed from October 2023 to June 2024.

MAIN OUTCOMES AND MEASURES: Self-reported health insurance coverage, reliance on VA insurance, and self-reported health.

RESULTS: Among a total of 3 644 614 survey respondents (mean [SE] age, 60 [0.04] years; 91.3% [95% CI, 91.2%-91.5%] male) included, 52.2% (95% CI, 52.0%-52.4%) were out of the labor market and 63.1% (95% CI, 62.9%-63.3%) were married. In 2010, 94% of all veterans and 94% of veterans younger than age 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment increased over time, and by 2020, 97% of all veterans and 95% of veterans younger than 65 years reported having health insurance coverage on the American Community Survey. Insurance enrollment estimates were similar across the surveys. Approximately one-third of veterans reported being enrolled in VA health coverage. Of those who enrolled in VA insurance, more than 75% had more than 1 form of coverage, with Medicare and private insurance being the most common second insurance sources. VA insurance enrollment was negatively associated with income and health status. Veterans without insurance tended to be unemployed and younger.

CONCLUSIONS AND RELEVANCE: This study of veterans who responded to 4 national surveys found that veterans enrolled in VA health coverage had high rates of dual coverage. Further legislative efforts to increase access without recognizing the high rates of dual coverage may yield unintended consequences, such payer shifting.

PMID:39186266 | DOI:10.1001/jamanetworkopen.2024.30205