Background The COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans’ ambulatory care experience, specifically access and satisfaction, early in the pandemic. Methods We employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 – June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis. Results Veterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers (“The phone would hang up on me”) and 9 (33%) reported a lack of provider availability (“They are not reaching out like they used to”). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0–10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)). Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), “I stay inside and away from people”). Conclusions While the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis.

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OBJECTIVE Morning glory disc anomaly (MGDA), a congenital abnormality of the optic nerve, may be associated with moyamoya arteriopathy, a cerebrovascular abnormality. In this study, the authors aimed to define the temporal evolution of cerebrovascular arteriopathy in patients with MGDA to characterize a rational strategy for screening and management over time. METHODS The records of pediatric neurosurgical patients at two academic institutions were retrospectively reviewed to identify cases of cerebral arteriopathy and MGDA, including radiographic and clinical records documenting patient outcomes of medical and surgical management. RESULTS Thirteen cases of moyamoya syndrome (MMS) associated with MGDA were identified in 13 children aged 0.6–17 years. The pattern of arteriopathy resembled that of non-MGDA MMS, with predominantly anterior circulation involvement. The arteriopathy lateralized with the MGDA, although 3 patients also had contralateral involvement. The overall group was followed for a median of 3.2 years. Radiological biomarkers of cerebral ischemia were applied to guide surgical decisions, and more than half of the patients (7 of 13) had evidence of stroke or progression on serial imaging. Nine patients underwent revascularization surgery, and 4 were managed medically. CONCLUSIONS Cerebral arteriopathy observed in association with MGDA resembles MMS seen in patients without MGDA and is dynamic, with progression observed over months to years and an associated risk of cerebral ischemia that indicates a role for surgical revascularization. Radiological biomarkers may augment clinical data to identify candidates for revascularization surgery.

Background The COVID-19 pandemic caused widespread practice changes to healthcare in all settings, but little is known about veterans’ experience with primary care during the early phase of the pandemic. Objective To characterize how COVID-induced changes affected the ambulatory care experience, specifically access and satisfaction, among Veteran users of primary care at a large urban Veterans Health Administration (VHA) medical center. Design: We employed a semi-structured telephone interview consisting of 56 questions to capture quantitative and qualitative data. We randomly selected potential participants from among patients who were scheduled to see any of 31 primary care physicians between March 1 – June 30, 2020 at a single location. We evaluated quantitative data using descriptive statistics and categorized open-ended qualitative responses using a matrix analysis. Participants: The study sample of 40 veterans largely consisted of men, almost equally split between non-Hispanic Whites and African Americans. The majority (22, 55%) of the veterans were members of Priority Group 1, the VHA eligibility group that requires either a greater than 50% disability rating or deemed unemployable. Many of the veterans had other insurance coverage, including TRICARE (21, 52.5%), Medicare (8, 20%), and private insurance (5, 12.5%). Main Measures/Approach: We sought to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and their non-VHA primary care source. We also explored the context of veterans' daily lives during the pandemic, knowing that many people’s mental health, relationships, and employment were impacted. Key Results: Veterans completed (mean 2.6) more appointments than scheduled (mean 2.3) due to urgent or ‘sick’ visits with a shift to virtual modalities like telephone (mean: 2.1) and video (mean: 1.5). Those who reported decreased access to care (27, 67%) as compared to before the pandemic cited administrative barriers (15, 56%) and lack of physician availability (9, 33%) as key factors. While most veterans (31, 84%) were highly satisfied with their care, 9 (24%) reported a decrease in satisfaction since the pandemic. The few veterans who utilized non-VHA physicians were slightly more satisfied with their care. None of the veterans interviewed contracted COVID-19 during the study period, but many experienced indirect psychosocial effects such as the worsening or development of mental health conditions (6, 15%), anxiety concerning the virus (12, 30%), social isolation (8, 20%). Conclusions While the quantitative data suggests continued adequate access and satisfaction, the numerous comments regarding barriers to care illustrate a disconnect between veterans’ perceived experience and the quantitative findings. Given the VHA system’s efforts to scale up virtual care and pandemic-related messaging, the comments of this sample of veterans suggest that enhanced or different approaches may be warranted to maintain perceptions of access and satisfaction with primary care during times of crisis.