Varsha G Vimalananda

• MD, MPH
• Medical Doctor at U.S. Department of Veterans Affairs

Objectives To identify determinants of continuous glucose monitoring (CGM) implementation from primary care providers’ (PCPs’) perspectives and examine the associations of these determinants with both PCP intent to discuss CGM with eligible patients and facility-level uptake of CGM. Study design Cross-sectional survey. Methods A survey about CGM...

Disclosure: V. Vimalananda: None. S. Qian: None. R. Bolton: None. A. Hung: None. V. Smith: None. M. Maciejewski: None. Introduction: Obesity is a prevalent and costly chronic disease that compromises quality of life; increases risks of cardiometabolic disease, osteoarthritis, and several cancers; and accounts for 28% of U.S. health care costs. Anti...

Electronic consultations (e-consults) are a mode of referral increasingly used to provide access to endocrine specialty care without the need for a patient in-person visit. This scoping review aimed to describe the models being used to deliver endocrine care via e-consult, what is known about outcomes of endocrine e-consult, and research gaps. The...

Background Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT...

Importance Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known. Objective To evaluate patterns of telemedicine use and their association with glycemic control among adults with va...

Objectives: Electronic consultations, or e-consults, which are requests for specialist advice without direct patient interaction, are becoming increasingly common across health systems. We sought to identify clinicians' perspectives on the quality of e-consult requests that they send and receive. Study design: A qualitative research study at the...

Background Post–COVID-19 condition is emerging as a new epidemic, characterized by the persistence of COVID-19 symptoms beyond 3 months, and is anticipated to substantially alter the lives of millions of people globally. Patients with severe episodes of COVID-19 are significantly more likely to be hospitalized in the following months. The pathophys...

BACKGROUND Post–COVID-19 condition is emerging as a new epidemic, characterized by the persistence of COVID-19 symptoms beyond 3 months, and is anticipated to substantially alter the lives of millions of people globally. Patients with severe episodes of COVID-19 are significantly more likely to be hospitalized in the following months. The pathophys...

Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss. To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with lon...

Background The COVID-19 pandemic required that our research team change our mail-only (MO) strategy for a research survey to a strategy more manageable by staff working remotely. We used a modified web-push approach (MWP), in which patients were mailed a request to respond online and invited to call if they preferred the questionnaire by mail or ph...

Introduction Use of telehealth for outpatient endocrine care remains common since onset of the COVID-19 pandemic, though the context for its use has matured. We aimed to describe the variation in telehealth use for outpatient endocrine visits under these “new normal” conditions and examine the patient, clinician-, and organization-level factors pre...

Disclosure: K. Arao: None. V. Vimalananda: None. Objective: Endocrinologists rely on information in the referral to guide the focus and scope of their evaluations. However, endocrinology referrals frequently lack important clinical information, which may increase the risk of inefficiency, errors, and adverse outcomes. This quality improvement proje...

Disclosure: V. Vimalananda: None. S. Qian: None. K.A. Arao: None. A. Leibowitz: None. M. Zupa: None. J. Benzer: None. M. Zocchi: None. G. Fincke: None. M. Meterko: None. D. Berlowitz: None. K. Sitter: None. J. Wormwood: None. Background: Use of telehealth (telephone or video) for outpatient care peaked early in the COVID-19 pandemic. Use has decrea...

Objective Outpatient diabetes mellitus (DM) care over video telehealth (TH) requires modifications to how endocrinologists complete physical examinations (PEs). But there is little guidance on what PE components to include, which may incur wide variation in practice. We compared endocrinologists’ documentation of DM PE components for in-person (IP)...

Context Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices. Objective To develop and validate quality measures around initiation and monitoring of testosterone prescribing. Design Retrospective cohort study. Setting Veterans Health Administration (VA) Participants A national cohor...

Objective: Endocrinology referrals frequently lack important clinical information, which may increase the risk of inefficiency and adverse outcomes. This quality improvement project aimed to improve the completeness of new referrals by utilizing structured referral templates for common endocrine conditions at a large Veterans Health Administration...

Background: Secure messaging use is associated with improved diabetes-related outcomes. However, it is less clear how secure messaging supports diabetes management. Objective: We examined secure message topics between patients and clinical team members in a national sample of veterans with type 2 diabetes to understand use of secure messaging fo...

This cohort study examines the association between same-day preoperative glycemic control and postoperative adverse events among patients with diabetes undergoing ambulatory hernia surgery.

Rationale: Telemedicine consults, including video consults, telephone consults, electronic consults, and virtual conferences, may be particularly valuable in the management of chronic pulmonary diseases, but there is limited guidance on best practices for pulmonary telemedicine consults. Objective: This scoping review aims to identify, character...

Introduction Patient-centred care and care coordination are each key priority areas for delivering high quality healthcare. However, the intersection between these two concepts is poorly characterised. We theorise that greater advancements in healthcare quality could be realised when care is organised in a way that aligns with patients’ preferences...

Objective Telehealth use rapidly increased during the COVID-19 public health emergency. While this preserved safe access to care, there was insufficient time to optimize telehealth implementation for its clinical users. We sought to understand endocrinologists’ experiences with synchronous telehealth to identify factors that influence successful im...

Background The increase in outpatient endocrinology care delivered by synchronous video telehealth during the COVID-19 pandemic is likely to persist post-pandemic. There is little data to guide endocrinologists’ judgments of clinical appropriateness (safety and effectiveness) for telehealth. We sought to examine how endocrinologists determine clini...

Objective Endocrinology is well-suited to telehealth, with high rates of use and known benefits. Clinician attitudes towards telehealth will be critical to ensuring sustained use post-pandemic. We examined endocrinologists’ experiences with synchronous telehealth to identify factors impacting experiences with and acceptance of the technology. Meth...

Objectives: To assess the feasibility and effectiveness of text messaging to increase outpatient care engagement and medication adherence in an urban homeless population in Boston. Methods: Between July 2017 and April 2018, 62 patients from a clinic serving a homeless population were sent automated text messages for four months. Messages were ei...

Objective This work aims to guide clinicians practicing endocrinology in the use of telehealth (synchronous patient-clinician visits conducted over video or telephone) for outpatient care. Participants The Endocrine Society convened a 9-member panel of US endocrinologists with expertise in telehealth clinical care, telehealth operations, patient-c...

BACKGROUND Secure messaging use is associated with improved diabetes-related outcomes. However, it is less clear how secure messaging supports diabetes management. OBJECTIVE We examined secure message topics between patients and clinical team members in a national sample of veterans with type 2 diabetes to understand use of secure messaging for di...

Background Outpatient endocrinology care delivered by telehealth is likely to remain common post-pandemic. There is little data to guide endocrinologists’ judgments of clinical appropriateness (safety and effectiveness) for telehealth by synchronous video. We examined how, in the absence of guidelines, endocrinologists determine clinical appropriat...

Objective: To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model. Materials and methods: We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conduct...

Objective: The study sought to investigate whether consistent use of the Veterans Health Administration's My HealtheVet (MHV) online patient portal is associated with improvement in diabetes-related physiological measures among new portal users. Materials and methods: We conducted a retrospective cohort study of new portal users with type 2 diab...

We used an online survey to measure how personal acquaintance with referring primary care providers (PCPs) affects specialists' experience of care coordination as use of a shared electronic health record (EHR) increases. Only 9% of specialists rated Overall Coordination as 9 or 10 out of 10. Personal acquaintance positively impacted Overall Coordin...

Background: Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination. Objective: The objective of this study was to understand pri...

Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is...

We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to i...

We sought to operationalize and validate data-driven approaches to identify transgender individuals in the U.S. Department of Veteran Affairs (VA) health care system through a retrospective analysis using VA administrative data from 2006 to 2018. Besides gender identity disorder (GID) diagnoses, a combination of non-GID data elements were used to i...

Objective Electronic consultations (e-consults) are commonly used to obtain endocrinology input on clinical questions without a face-to-face visit, but there are sparse data on quality of care resulting from e-consults for specific conditions. We examined workups resulting in thyroid nodule fine-needle aspiration (FNA) biopsy to examine whether end...

Background: Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration. Object...

Background: We previously developed 2 complementary surveys to measure coordination of care as experienced by the specialist and the primary care provider (PCP). These Coordination of Specialty Care (CSC) surveys were developed in the Veterans Health Administration (VA), under an integrated organizational umbrella that includes a shared electronic...

Background: Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination. Objective...

Research Objective Coordination of care between specialists and primary care clinicians (PCCs) is a critical component of providing patients with high‐quality specialty care. Previous research has demonstrated care coordination may benefit from use of a shared electronic health record (EHR). Yet reliance on a shared EHR may undercut opportunities t...

Background Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients’ involvement in their care. However, little is known about the pathways through which portals may help...

Objective To assess the psychometric properties and construct validity of a survey of primary care providers' (PCPs’) experience of specialty care coordination, which is a counterpart to our existing survey ("CSC‐Specialist") that measures specialists’ experience of specialty care coordination. Data Sources We surveyed PCPs from Veterans Health Ad...

Background: Diabetes is a complex, chronic disease that requires patients' effective self-management between clinical visits; this in turn relies on patient self-efficacy. The support of patient autonomy from healthcare providers is associated with better self-management and greater diabetes self-efficacy. Effective provider-patient secure messagi...

Introduction: Coordination of care between primary care physicians (PCPs) and specialists is crucial in providing safe, efficient specialty care for referred patients, but shortcomings in coordination are common. Objective: Examine endocrinologists’ experience of coordination with PCPs and examine the relationship of a shared EHR to coordination. M...

BACKGROUND Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients’ involvement in their care. However, little is known about the pathways through which portals may help...

BACKGROUND: Hypoglycemic events are common and potentially dangerous conditions among patients being treated for diabetes. Automatic detection of such events could improve patient care and is valuable in population studies. Electronic health records (EHRs) are valuable resources for the detection of such events. OBJECTIVE: In this study, we aim to...

Objective: Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access,...

Objectives: Referrals from primary to specialty care are a critical first step in coordination of specialty care, but shortcomings in the appropriateness, clarity, or completeness of referrals are common. We examined (1) whether 3 tools to coordinate specialty care are associated with better referral characteristics and (2) whether greater perceiv...

Background Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes.Objective To determine how cardiovascular and mental healt...

Background Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships...

Objective Weight‐management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight‐management program. Methods We conducted a retrospe...

Objective: Overweight and obesity affect over 4 million veterans receiving health care in the Veterans Administration (VA). In VA, WMM are available to any Veteran who is engaged in behavioral weight management and meets BMI criteria. In 2010, weight management medications (WMM) were found to be underused in VA, but since then new WMM have been app...

Objective To develop an online survey of care coordination with primary care providers as experienced by medical specialists, evaluate its psychometric properties, and test its construct validity. Data Sources Physicians (N = 633) from 13 medical specialties across the Veterans Health Administration. Study Design We developed the survey based on...

Background Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achie...

Background Improper dosing of medications such as insulin can cause hypoglycemic episodes, which may lead to severe morbidity or even death. Although secure messaging was designed for exchanging nonurgent messages, patients sometimes report hypoglycemia events through secure messaging. Detecting these patient-reported adverse events may help alert...

Introduction: E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care. Methods: This is a retrospective analysis of 750 patien...

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experi...

Background: Many health care systems now allow patients to access their electronic health record (EHR) notes online through patient portals. Medical jargon in EHR notes can confuse patients, which may interfere with potential benefits of patient access to EHR notes. Objective: The aim of this study was to develop and evaluate the usability and c...

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and en...

Background: Recent emphasis on value based care and population management, such as Accountable Care Organizations in the United States, promote patient navigation to improve the quality of care and reduce costs. Evidence supporting the efficacy of patient navigation for chronic disease care is limited. The objective of this study was to evaluate t...

Background. Intensive glycemic control confers increased risk of hypoglycemia and little benefit among older individuals with diabetes. The aim of this quality improvement project was to reduce the number of patients treated to A1C levels that might confer greater risk than benefit (i.e., potential overtreatment) in the VA New England Healthcare S...

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site provid...

Objective: Weight loss was examined among women and men veterans in a clinical trial comparing Aspiring for Lifelong Health (ASPIRE), a "small changes" weight loss program using either mixed-sex group-visit or telephone-based coaching, to MOVE!(®) , the usual mixed-sex group-based program. Methods: Linear mixed-effects models were used to calcul...

Rationale, Aims and Objectives: Provider decisions to intensify antihypertensive medications are usually based on clinical metrics (i.e., blood pressure control), but may also be based on patient provided information. When providers use a participatory questioning style, patients share more information and providers may identify barriers to blood p...

Background: Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consul...

Background: We define electronic consultations (‘‘e-consults’’) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was t...

Drs. Kivimaki and Singh-Manoux (1) comment on our recent article (2) about symptoms of depression, antidepressant use, and incident diabetes in U.S. black women. In particular, they raise the possibility that the reported association between antidepressant use and increased risk of type 2 diabetes (2 …

The aim of this study was to assess shift work in relation to incident type 2 diabetes in African-American women. In the Black Women's Health Study (BWHS), an ongoing prospective cohort study, we followed 28,041 participants for incident diabetes during 2005-2013. They answered questions in 2005 about having worked a night shift. We estimated HR an...

Objective: To assess the association of birth weight with incident type 2 diabetes, and the possible mediating influence of obesity, in a large cohort of U.S. black women. Research design and methods: The Black Women's Health Study is an ongoing prospective study. We used Cox proportional hazards models to estimate incidence rate ratios (IRRs) a...

OBJECTIVE To assess the relationship of depressive symptoms and use of antidepressants with incident type 2 diabetes in prospective data from a large cohort of U.S. African American women.RESEARCH DESIGN AND METHODS The Black Women's Health Study (BWHS) is an ongoing prospective cohort study. We followed 35,898 women from 1999 through 2011 who were...

Hypertension, hyperlipidemia, diabetes, and obesity in middle adulthood each elevate the long-term risk of cardiovascular disease (CVD). The prevalence of these conditions among women veterans is incompletely described. To describe the prevalence of CVD risk factors among women veterans in middle adulthood. Serial cross-sectional studies of data fr...

Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds. To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk. Retrospective cohort study. Veterans Health Administ...

OBJECTIVE To assess the relationship of depressive symptoms and use of antidepressants with incident type 2 diabetes in prospective data from a large cohort of U.S. African American women. RESEARCH DESIGN AND METHODS The Black Women’s Health Study (BWHS) is an ongoing prospective cohort study. We followed 35,898 women from 1999 through 2011 who we...

Aims It is unknown whether sex differences in the association of diabetes with cardiovascular outcomes vary by race. We examined sex differences in the associations of diabetes with incident congestive heart failure (CHF) and coronary heart disease (CHD) between older black and white adults. Methods We analyzed data from the Cardiovascular Health...

We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia. We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of...

To compare diabetes care and outcomes among Haitians, African Americans, and non-Hispanic whites. We analyzed data from 715 Haitian, 1,472 African American, and 466 non-Hispanic white adults with diabetes using χ² testing and multiple logistic regression. Haitians had a higher mean A1C than African Americans (8.2 ± 1.9 vs. 7.7 ± 2.0%) and non-Hispa...

Diabetes-related care and complications constitute a significant proportion of the United States' (US) health care expenditure. Of these complications, cardiovascular disease (CVD) is a major component. Higher morbidity and mortality rates translate to higher costs of care in patients with diabetes compared to those who do not have the disease. Min...