There are 8.8 million American veterans aged >65 years. Older veterans often have multiple health conditions that increase their risk of social isolation and loneliness, disability, adverse health events , mental illness, and heavy health care use. This population also exhibits low levels of physical function and daily physical activity, which are factors that can negatively influence health. Importantly, these are modifiable risk factors that are amenable to physical therapy intervention. We used a working model based on the dynamic biopsychosocial framework and social cognitive theory to conceptualize the multifactorial needs of older veterans with multiple health conditions and develop a novel, 4-component telehealth program to address their complex needs.This study aims to describe veterans’ experiences of a multicomponent telehealth program and identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to collect their feedback on this novel program; explore their experience of program components; and document perceived outcomes and the impact on their daily life, relationships, and quality of life.As part of a multimethod program evaluation, semistructured interviews were conducted with key informants who completed ≥8 weeks of the 12-week multicomponent telehealth program for veterans aged ≥50 years with at least 3 medical comorbidities. Interviews were audio recorded and transcribed. Data were analyzed by a team of 2 coders using a directed content analysis approach and Dedoose software was used to assist with data analysis.Of the 21 individuals enrolled in the program, 15 (71%) met the inclusion criteria for interviews. All 15 individuals completed 1-hour interviews. A total of 6 main conceptual domains were identified: technology, social networks, therapeutic relationship, patient attributes, access, and feasibility. Themes associated with each domain detail participant experiences of the telehealth program. Key informants also provided feedback related to different components of the program, leading to adaptations for the biobehavioral intervention, group sessions , and technology supports.Findings from this program evaluation identified quality and process improvements, which were made before rigorously testing the intervention in a larger population through a randomized controlled trial. The findings may inform adaptations of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change. There are 8.8 million US veterans aged >65 years . ApproxiAlthough the VA has multiple established telehealth programs to assist veterans, no existing telehealth physical rehabilitation programs incorporating technology supports are tailored to older veterans with multimorbidity and complex health needs. For example, the MOVE! program is a weight management program that focuses mostly on nutritional education and coaching. The MOVE! program encourages routine physical activity as a strategy to support weight management; however, this program may not meet the needs of veterans with limitations in physical function, and not all locations offer exercise classes. Similarly, the VA Gerofit program is an exercise program designed for veterans aged ≥65 years, but the synchronous video telehealth version of the program requires veterans to demonstrate independence with exercises in a group setting, with or without caregiver assistance, and excludes those who require supplemental oxygen. As such, many veterans with multimorbidity and actual or perceived barriers to exercise are unable to participate in Gerofit.Traditional physical rehabilitation programs can help prepare veterans to transition to community programs such as MOVE! and Gerofit; however, traditional episodes of care involve few sessions and often end before veterans are able to make such a transition. We sought to fill this gap by developing and evaluating a multicomponent telehealth program designed to address the complex needs of veterans with multimorbidity, teaching skills to support behavior change, and improving physical function so that the transition to community programs could be possible.The purpose of this qualitative program evaluation was to describe the experiences of a multicomponent telehealth program and to identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to (1) explore their experience of individual program components; (2) document perceived outcomes and the impact on their daily life, relationships, and quality of life; and (3) collect feedback on this novel program to inform adaptations.We conducted a multimethod program evaluation of our telehealth program. Quantitative results will be published separately. The focus of this study is to detail qualitative findings in relation to participant satisfaction, feedback, experience with key program components, and self-reported outcomes. This study follows the Consolidated Criteria for Reporting Qualitative Research guidelines  and the The telehealth program was conducted as a joint project between the VA Eastern Colorado Healthcare System’s Geriatric Research Education and Clinical Center and the University of Colorado. All physical therapists were doctoral trained, 2 were board-certified geriatric clinical specialists, and 1 was completing a Geriatric Clinical Specialist residency.The members of the program evaluation group included 2 clinical researchers (LMA and JES-L), 2 qualitative researchers (MLM and KAN), 1 physical therapist (MRR), and 1 research assistant. KAN also has >25 years of experience conducting program evaluations, including state-wide and national evaluations. Neither qualitative researcher had a therapeutic relationship with key informants to minimize the potential for bias.We combined 1 framework and 1 theory to develop a conceptual model for the multicomponent telehealth program . A conceWe used our conceptual model to develop a 4-component telehealth program that addresses the complex and multifactorial needs of older veterans. coaching) delivered using motivational interviewing techniques, (3) social support during group physical therapy sessions, and (4) technology to augment intervention delivery (synchronous videoconferencing) and enhance participation . The 12-week multicomponent program was delivered by licensed physical therapists and a physical therapy assistant. The four core components of the program were (1) high-intensity rehabilitation  delivereParticipants were provided with exercise equipment, vital sign monitoring equipment, and a Fitbit Versa 2. All participants received at least 5 THERABAND resistance bands  and adjustable ankle weights. Participants received other exercise equipment such as an aerobic step, when needed. All participants who did not own vital sign monitoring equipment were provided with a pulse oximeter and an automatic blood pressure monitor. Participants who did not have a video-capable device received one through the VA’s digital divide program. A physical therapist taught participants how to use the exercise and vital sign monitoring equipment during a program orientation session, and an assistant taught participants how to set up the Fitbit.Individuals were purposively sampled from a cohort that participated in the telehealth program. The eligibility criteria for the telehealth program were as follows: veteran and veteran spouse, age ≥50 years, ≥3 medical comorbidities, and self-reported reduced physical function . Any chronic medical condition listed in the participant’s chart was included in the total number of comorbidities; duplicative and similar entries were counted only once; for example, low back pain, degenerative disc disease, and lumbar stenosis were counted as 1 medical condition. Veterans were excluded if they had severe dementia , life expectancy <12 months, or a medical condition that would preclude safe participation in high-intensity rehabilitation . Veterans were eligible for semistructured program evaluation interviews if they experienced all 4 components and participated in at least 8 weeks  of the telehealth program. A member of the team (MRR) verbally consented eligible participants.In total, 60-minute semistructured interviews were conducted between March and September 2021 using VA Video Connect, a secure videoconferencing platform. This platform was also used for all telehealth program sessions. The interviews involved 1 veteran and 2 program personnel (KAN and MRR or a research assistant). Interviews were conducted primarily by KAN, whereas MRR was present to take notes and ask detailed questions pertaining to the technology components of the program. Although MRR had a therapeutic relationship with some key informants, we encouraged candid feedback by explaining that the goal of the interview was to improve the telehealth program by learning about participants’ experiences.An interview guide was used to focus the interview on veterans’ experiences of the program as they related to our objectives . The guiPatient information, including rural status, miles saved, age, biological sex, BMI, functional comorbidity index , race, eself-efficacy was a salient construct from SCT  person, it’s real fluid. I can [log-on to VA Video Connect] in, like, two minutes now.Veteran #211Often, veterans found one technology easier to use than others, with the Fitbit and Annie being among those used most often to monitor progress. Participants reported a variety of methods for setting up and maintaining technology tools. One veteran shared, for example:The Fitbit was easy. I said, “Here, honey [referring to his wife], program this for me”Veteran #211Help-seeking resources included asking family members for help, as seen in the quote from veteran #211, calling dedicated helplines , and searching the internet for videos or articles. Our team also provided orientation sessions to help participants set up and become familiar with technology tools and provided ongoing support.“Sometimes [Annie] was annoying and sometimes it was helpful”—but was satisfied with the Fitbit—“I love the sleep part of [the Fitbit] ‘cause it tells me how my sleep is going. I see my sleep doctor once a year, and now I can actually share this information with them to let them know how I am sleeping.” Participants tended to be satisfied with a specific technology when they associated its use with a benefit. This value-driven satisfaction was evident when veterans discussed how the technology fostered a sense of encouragement to be active or held them accountable to the program and their goals:The level of satisfaction varied even for the same individual, depending on the specific technology being discussed. For example, veteran #221 was ambivalent about Annie—Like it was Team [me]. Like, [Annie] was my little other coach. So, like, she was my third coachVeteran #105Some veterans expressed dissatisfaction with the various technologies; this feeling often emerged when there was no value seen in the technology. For example, a veteran did not find value in the text messages from Annie:For me, Annie was nothing but annoying. I did not need encouragement from Annie.Veteran #226At other times, dissatisfaction was expressed when using the technology was inconvenient or required extra steps:I can’t tell you how thrilled I was when [the text messages] stopped. It was just an irritation that I had to take time, go to another screen, and look to find out the information I needed to know, connected with Annie.Veteran #217Statements of accountability emerged primarily when veterans were discussing the Fitbit and Annie. Some veterans noted how the Fitbit helped to provide accountability because it became a source of feedback on a person’s daily activities by providing them with data. Having knowledge of these data allowed veterans to set goals and monitor their progress, fostering a sense of personal accountability. Annie most often provided accountability through the consistency of the text messages asking for daily step counts:I knew that at 8:00 and 11:00 every night, Annie would be wanting my steps.Veteran #220When veterans set daily step count goals, the Fitbit tracking and Annie reporting functions seemed to work synergistically to keep veterans accountable.The program staff sought to intentionally foster peer comradery during group physical therapy sessions. Most veterans noted that peer comradery was present and often facilitated through the shared experience of being veterans; this comradery enhanced their experience of the program overall. Peer comradery, when present, can support the emergence of friendly competition among participants, often motivating them to increase their effort:I tried to do more than these guys—the young guys, you know, the 55- and 60-year-olds.Veteran #208Not all participants who described comradery also described this experience of friendly competition, a finding that suggests that this perception was also tied to a veteran’s personality, prior experiences, or group dynamics.In contrast, some veterans described the absence of comradery. This lack of comradery was influenced by one or more of the following factors: (1) the veteran experienced a small group of only 1 to 2 people owing to slow program enrollment, (2) the group comprised veterans at very different levels of physical function, or (3) the veteran perceived a lack of personality fit. The following quote illustrates the absence of comradery stemming from having varying levels of physical function and personalities within different groups:Part of the problem for me, too, is that I was either grouped with people...with a lot more limitations and adaptions that needed to be done and older and more frail situations, it seemed. The second one was strictly your kind of proverbial GI Joe, and he was not a very pleasant GI Joe. And so, it just was not a good mix because I'm somewhere else in the spectrumVeteran #223These differences also contributed to feelings of frustration if a veteran was unable to participate at a desired intensity, for example, when patients with higher physical function and capacity needed to slow down or have longer rest breaks to accommodate veterans with lower physical function and capacity.Some participants described having close familial relationships, which they indicated were instrumental throughout the program, for example, by helping participants manage the technical aspects of participation. Relationships outside the program often served as additional sources of motivation for program participation, especially when spouse- or family-centered activities were important to the individual:[My wife and I] play music in the kitchen, and when we’re cooking, we dance together. I couldn’t do that [before the program]...I mean, just to be able to enjoy our company the way we had before my knee started going so bad, was -- hey, life’s a great pleasure.Veteran #211These external relationships also played a role in the plans to continue exercise.Most participants identified trust as the keystone of the therapeutic relationship, and trust played a critical role in their overall experience of the program. Veterans noted that their therapists established trust through various mechanisms. One method was by proactively addressing potential safety hazards in the home environment and by being responsive to patients’ concerns:There wasn’t [a time I felt uncomfortable doing an exercise] because the therapists made sure that we had a chair, a grab rail, something there in case we lost our balance.Veteran #221Veterans perceived trust as a facilitator for program engagement. Sometimes, trust was not established with clinicians, and perceptions of not having enough time to work with a clinician or clinicians other than their primary individual physical therapist surfaced as a barrier to the emergence of trust. Clinicians’ qualities, communication, and personalization have also contributed to the development of trust.Veterans viewed trust as bidirectional, in that the clinician also needed to demonstrate trust in the patient and their judgment. One participant identified how she perceived that her physical therapist had trust that she would follow through with the plan of care when she needed to transition to an asynchronous telehealth approach because she was no longer able to attend the scheduled group sessions:I knew that I had established trust with [my physical therapist] and that we also had formulated a really good connection, and that she was wanting to see my success as much as I wanted to stay in the program.Veteran #105In contrast, 1 veteran provided an example of how he felt the clinician did not trust his interpretation of pain during exercise. He stated the following with exasperation:I said, “Oh, that one—that one caused some pain. That was a good work out.” And [the clinician leading the group session stopped] the whole dang thing ‘cause I used the trigger word pain. Just ‘cause you feel it, doesn’t mean you’re hurt. Just ‘cause there’s pain, doesn’t mean you’re injured!Veteran #226This excerpt also identifies the importance of communication between the patient and the clinician.Clinicians’ qualities contributed to the therapeutic relationship, and key informants often described their therapists as motivating, caring, informative, encouraging, kind, professional, and attentive:That’s the advantage to having someone paying attention to what you’re doing and trying to convince you to do better, as well as having a whole program where you’ve got some caring people that encourage you to do better.Veteran #220Veterans often expressed that their coaches and therapists were a source of accountability:[The coach] put into perspective my part ‘cause it gave me accountability.Veteran #109These positive clinician qualities helped establish a strong therapeutic relationship and made patients feel valued and respected:I have never had this kind of care in my life...I have never had this good of care period.Veteran #227Most participants felt that there was beneficial and constructive communication, especially with their individual physical therapist or coach. Collaborative communication was often key in developing the therapeutic relationship:A lot of providers can be very cold. It’s just like, you know, people are talking at you instead of talking to you. And at no time during the course of this program did I feel that anybody was talking at me. They were really concerned for me and for me, uh, improving, being better, getting stronger.Veteran #104Veterans appreciated hearing about their progress during reassessments and gaining new knowledge about exercise and movement. However, there were also instances when there was a lack of communication, and although this may not have been perceived as a negative experience, the participants viewed such instances as a missed opportunity. For example, 1 veteran noted the following:We’re meeting Monday, Wednesday, Friday. On Tuesday and Thursday and then the weekends, this is what I want you to do. That instruction was lacking.Veteran #226Veterans also noted that most communication deficiencies occurred during group sessions, especially if the physical therapist leading the group was not the same clinician who led their individual physical therapy sessions. In some instances, this created an environment that fostered a negative experience for veterans:This [physical therapist] didn’t really know me from anybody, had no foundation with me. So, if they don’t know me, how can they suggest what is a good exercise for me?Veteran #223We also heard similar experiences when veterans saw multiple therapists throughout the program.Domain 4: Personal Attributes section) and developing trust:Individual physical therapy sessions, which occurred before the transition into group sessions, facilitated the therapist’s ability to tailor the exercise program to each participant’s needs and goals. Sometimes, this tailoring involved connecting certain exercises to a patient’s motivation for participation; for example, the squat exercise is used to build leg strength so that for one patient, it will be easier to get in and out of a chair, and for another patient, it will be easier to pick up their grandchild. At other times, personalization required the therapist to identify an alternate exercise to address certain muscle groups without exacerbating pain. For example, if the goal is to strengthen the quadriceps muscles, but a standing squat is painful, this exercise could be modified to a seated knee extension; this facet of personalization was important for facilitating changes in attitudes and beliefs  versus joint pain , helping to learn or reinforce body awareness while minimizing fear of injury:The veterans described the current and past attitudes and beliefs related to exercise and pain that influenced their experience of the program. Most patients identified that exercise was or had become an important part of their life. For some veterans, this was a new attitude, whereas for others, it was a persistent belief, and the program served as a source of support for reestablishing regular exercise habits. Some veterans who were hesitant to exercise before the program owing to pain realized that there were alternative ways to exercise without experiencing pain; this was a key mechanism through which therapists enhanced the therapeutic relationship while also helping patients break out of fear-avoidance behaviors. Some patients also described learning the difference between expected muscle soreness  and physical examination . Care expectations may have contributed to the difficulty that some participants described engaging in the coaching sessions:We sat there and talked, and maybe because I wanted to do things—I didn’t want to just talk for a half hour—and so that’s why maybe I didn’t get anything out of [the coaching].Veteran #208Some patients also expected a more traditional communication style during physical therapy  rather than the guiding and following communication styles used as part of the motivational interviewing techniques. Interestingly, some veterans noted a need for self-advocacy in the telehealth setting, which may not need to happen to the same extent during in-person physical therapy:The Veteran has to own a little bit of responsibility for sure. If I’m being a big boy and doing this over the tele-rehab thing, I’ve got to be a big enough boy to look and see that there’s swelling that isn’t being addressed with ice and etc., and I need to bring that up.Veteran #221The core equipment used during the program and provided to patients on an as-needed basis included monitoring equipment (automated blood pressure cuff and pulse oximeter) and exercise equipment . The participants were trained on how to use their equipment and how to set up their exercise equipment safely in their home. Most veterans either had access to the necessary equipment at the beginning of the program or felt that we adequately provided what they needed. The patients shared their feedback on the equipment used. For example, 1 veteran stated that he enjoyed using the aerobic step. However, he did not feel safe using the risers to increase the height of the step because it seemed unstable to him. He also noted that it was difficult to maneuver at home because it was a large step.Two key themes emerged in relation to efficiency: time efficiency and cost efficiency. Veterans identified time efficiency primarily as the reduced time required to travel to and from a facility to receive physical therapy. For some individuals who relied on public transportation or services such as Access-a-Ride for transportation, this was a significant time saving. Veterans also noted cost savings related to transportation, mostly stating that they did not have to pay for gas. The themes of time and cost efficiency were often intertwined for individuals who were working. These veterans described being able to participate in the synchronous videoconference exercise sessions either during their lunch hour or by adjusting their workday to accommodate the therapy sessions. They viewed the time saved as a cost saving because it meant taking less sick leave from work or preventing lost revenue for those who were self-employed.Participants often talked about convenience in relation to being able to receive physical therapy services on a day and time that worked for their schedule, thus facilitating access. Many veterans found that individual sessions were much easier to fit into their schedule than the group sessions. This sentiment was especially true among patients who were working full time because the group sessions occurred on set days and times and were thus more difficult to attend. For some participants, the inflexibility of the group sessions was a barrier to accessing this program component. Patients also appreciated the convenience of being able to perform physical therapy from their home—an environment that was logistically easier and, perhaps, more socially comfortable than other settings:I like the format; I like the video. I hated going to the gym. I hated going to the fitness centers and things like that where everybody else is, you know, and going into the locker rooms. It was just a pain.Veteran #220This telehealth program offered a solution to barriers that might have otherwise precluded receiving physical therapy as in-person care. Some veterans described physical health conditions that made it difficult to leave their home or drive. Other veterans noted that mental health conditions, such as social anxiety, made it difficult to attend in-person physical therapy. Such anxiety may have impacted their willingness to continue participation over the 12 weeks had the program been in person. Finally, owing to the timing of this program during the COVID-19 pandemic (2021), many veterans were wary of spending extended time in public spaces when there were alternative options available. Concerns about COVID-19 were particularly salient given the medical vulnerability of the population. For these reasons, the telehealth program offered an attractive solution for receiving physical therapy services. For some rural veterans, telehealth was the only option to access physical therapy services through the VA because they lived too far away from a VA facility.Overall, veterans found the frequency and duration of the program to be appropriate, especially when there was value or benefit seen from attending the sessions:There’s enough continuity that [the program] works well. You know, [if you’re] only doing it once a week I don’t know that we can see any substantial improvement in ourselves, but doing it, you know, three times a week and then having a counseling session to talk through goals and objectives...That, I think is great.Veteran #104Others were ambivalent about the program’s logistics, whereas some veterans identified the frequency of sessions and the duration of the program as burdensome. This perception often changed depending on competing priorities.The extent to which individuals viewed the program’s separate components as manageable also related to the perceived value. There was a subgroup of veterans who did not find value in the coaching sessions; thus, they felt that these additional sessions were burdensome:[The coaching sessions] were kind of lame and not helpful. Build goals. You know, for me it was frustration to have those sessions. [Veteran #223]Most veterans felt they were adequately prepared to make the transition from a higher level of supervision in the individual sessions to a lower level of supervision in the group sessions. The sense of preparedness was often a reflection of the quality and content of communication between the provider and the patient:I think the people that worked with me knew what I should be ready for and started on the individual at the beginning and then working into the group. I know [my individual physical therapist], every once in a while, would say, “You’ll experience this one in group.”Veteran #228Interestingly, 1 veteran viewed the individual sessions as being more important for the clinicians to prepare for group sessions:[The] individual session was more a preparation for them [clinicians] to deal with each of us individually than it was preparing me for a group session.Veteran #211A small group of veterans felt that the individual sessions did not prepare them for the exercises included in the group sessions:None of the stretching that you learned in your individual sessions translate or moved over into the group session.Veteran #225Notably, this perception seemed to occur when the physical therapist deviated from the protocol, often attempting to better meet the patient’s individual needs.Overall, the perceived benefits facilitated program engagement. Most participants reported improvements in physical health, and some veterans also reported improvements in mental health such as improved mood and enhanced self-efficacy, for example:I’m confident enough I can  because of the success in the program.Veteran #211Self-reported changes in physical and mental health were often related, and veterans noted that improvements in physical health enhanced both mood and mental health. One veteran also noted that before the program, visiting her children and grandchildren out of state was not possible for multiple reasons, including her physical health, chronic pain, and concerns about contracting COVID-19; however, following the program, she mentioned that she was considering traveling to see her children and grandchildren because she had less pain, was able to move around easier, and was able to get a COVID-19 vaccination. Some veterans reported negative outcomes. Two veterans experienced injurious falls while they were enrolled in the program. Although both instances occurred outside the therapy sessions and were unrelated to program interventions, these injuries either delayed or prevented progress during the program:Throughout the program, I was hurt, so that was somewhat of a hindrance.Veteran #207The purpose of this evaluation was to explore veterans’ experiences of a multicomponent telehealth program and identify opportunities for improvement. Key informants discussed positive experiences during the program, reinforcing specific program components and processes. Most key informants identified physical health improvements such as improved strength and energy, whereas some described mental and social health improvements including improved mood and the ability to return to valued activities. Key informants also described changes in or reinforcement of positive exercise attitudes and beliefs. Some veterans noted specific negative experiences, which informed program modifications.We used our conceptual model to design the multicomponent telehealth program by connecting intervention components to theoretical constructs. Component 1, high-intensity rehabilitation, was related to biological factors  and physical outcome expectations (SCT). Veterans attributed physical health improvements—improved muscle strength, enhanced balance, and greater daily energy levels—to the high-intensity rehabilitation component of the telehealth program. Some participants expressed an intention to continue doing at least some of the exercises after program completion, demonstrating positive health behavior changes. There is robust evidence to support physical health improvements following various exercise interventions . FurtherComponent 2, biobehavioral intervention (coaching), was designed to address psychological factors  and self-evaluative outcome expectations, self-efficacy, and goals (SCT). Key informants’ expectations for physical therapy seemed to influence their expectations regarding the content of coaching sessions. Those who expected coaching sessions to include traditional physical therapy interventions  tended to perceive low value in these sessions. Perceived benefits from coaching included identifying motivations for change, enhancing self-efficacy, and goal setting. Prior research has shown that behavior change interventions, similar to our coaching intervention, often include these strategies ,36. CoacPhysical and mental health were mentioned concurrently by some veterans who noted that improvements in physical health improved mood and mental health. This relationship is supported by robust evidence showing that exercise improves mood in individuals with mental health conditions ,38. SomeComponent 3, group physical therapy sessions, was related to interpersonal factors  and social outcome expectations (SCT). Many veterans reported a feeling of comradery, which not only enhanced their participation but also served as a source of external motivation for some. These findings are consistent with studies of in-person groups that demonstrated enhanced motivation and adherence ,40. A loDespite most veterans’ positive experiences in the group exercise sessions, some veterans had a neutral or negative group experience. Machielse  developeIn addition to group experiences, some veterans discussed how the program impacted their interpersonal relationships external to the program. The veterans who spoke about their social relationships noted that the physical benefits of the program enhanced their ability to participate in activities they valued with their family or friends and made them less dependent on others for assistance with daily activities and household chores. Furthermore, at least 2 veterans discussed how either their spouse or family member was central to the plans they made to continue exercising following the program. Not all key informants described changes in social health and interpersonal relationships outside of the program. Such variable experiences are likely contingent to some degree upon existing social networks and interpersonal dynamics that may be beyond the purview of the program’s influence.Program Adaptations section.Component 4, technology, was used to address contextual factors  in which this program occurred and barriers and facilitators to behavior change (SCT). Generally, the technology facilitated program engagement, primarily through synchronous video visits. The Fitbit and Annie facilitated behavior change for some participants by supporting monitoring and accountability. Experiences using the Fitbit were similar to those reported by Andersen et al , who stuVeterans participated in the program during the early months of the COVID-19 pandemic. Efforts taken to reduce viral spread resulted in canceled facility-based appointments and longer wait times for physical therapy. During the early stages of the pandemic, the VA implemented a triage system in which only high-priority patients were seen in person, including those with conditions that, if left untreated by physical therapy, would have lasting detrimental health effects. This environment increased the demand for and acceptance of the telehealth program, especially among older veterans with multiple chronic conditions and compromised immune systems. Some participants voiced that these concerns served as an impetus for participating in the telehealth program. Because of this unique context , it is unclear whether veterans will continue to view this program as feasible and acceptable after the pandemic. Finally, rurality can be a significant barrier within the VA system to receiving in-person care and is often a reason cited to support the expansion of telehealth services for a variety of specialties -47. Of tKey informants provided detailed feedback regarding the program components, enabling us to identify opportunities for improvement. Primary program adaptations were identified for the biobehavioral intervention (coaching), group sessions , and technology supports. The coaching sessions were not as acceptable to veterans as compared with the more traditional components of the physical therapy program for a variety of reasons, including the increased time commitment and lack of perceived value. The program staff also recognized that separating the coaching sessions resulted in a greater workload. Thus, we opted to integrate the coaching sessions into the individual physical therapy sessions for future iterations of the program. Findings from this program evaluation also highlighted the need to educate participants about the coaching component to enhance engagement.Some participants perceived a lack of communication among the clinicians when transitioning from individual sessions to group sessions. Veterans in the latter half of the program often had a different physical therapist for their group sessions. Although our team had processes in place for team communication, this feedback prompted us to revisit these processes. We conducted weekly patient round meetings to ensure that the group therapist had all the information necessary for a successful transition. For the current iteration of the program, the group lead therapist joins an individual session before the first group session, when possible, to meet the veteran and observe how they exercise. This adaptation has been helpful for both veterans and the clinicians. Some difficulties experienced transitioning to the group sessions were a result of deviation from the telehealth protocol, and as a result, we developed a fidelity checklist to serve as both an assessment of intervention fidelity and an opportunity for ongoing staff training and feedback. Furthermore, within the group sessions, some veterans did not feel comfortable sharing health-related information, which was sometimes necessary to supplement information obtained privately during pre- and postvisit calls. To address this concern in the current program iteration, we work with each veteran to develop a communication plan in the event that they need to leave the session suddenly for a nonmedical emergency or they need to speak privately with staff during the session.For the technology, we received feedback related to both the Annie text messaging protocol and the Fitbit activity monitors. Although most veterans enjoyed the text messages from Annie, some veterans did not want to receive certain messages or preferred to receive messages less often. On the basis of this feedback, we added more flexibility to the program’s protocol to allow for adjustments to the text messages, as needed. The veterans who enjoyed engaging with Annie also noted that they wished there was a way to respond to some of the 1-way text messages, typically those pertaining to goals. Because of this feedback, we updated the protocol to include 2-way text message templates that ask about goals. On Mondays, veterans were asked if they had set a weekly goal (yes or no response), and on Fridays, veterans were asked about their progress toward their goal . Regarding the activity monitor, most individuals used the Fitbit to monitor their daily step count; although this was sufficient for most veterans, other veterans felt that there were missed opportunities to use additional features of the activity monitor, such as those that help monitor sleep hygiene or track exercise intensity, and they perceived that the program staff were unaware of these additional data. As a result, we purposefully integrated Fitbit training into staff training, and we added veteran Fitbit training to the biobehavioral intervention protocol.This was a program evaluation, and as such, the results of this evaluation are not generalizable beyond this specific program. Although the findings may be helpful for others who would like to start a similar program, local adaptations may be needed for the program to be successful in different contexts. The qualitative data provided information about different program components; however, the outcomes associated with some aspects of the program remain unclear. For example, we heard limited information about how the veterans perceived the group sessions to impact their social health, if at all. Although veterans participated in up to 24 group sessions, not all veterans were able to experience a robust group because of program challenges that impacted our ability to maintain a steady census. As a result, some veterans completed group sessions during which they were the only individual in the group. We also did not interview participants who withdrew before 8 weeks of the program, and it is possible that we did not capture some of the barriers associated with program participation. Future program evaluations and research studies should include such individuals to understand their experiences. Interviews were also conducted immediately after the end of the program; therefore, we do not know how the program may contribute to longer-term outcomes. Furthermore, we had limited information about what behavior change skills veterans perceived to be the most helpful and how those skills would continue to be used in the future.The findings from this qualitative program evaluation supported ongoing quality and process improvements. The key facilitators for program engagement that emerged were the development of both a trusting therapeutic relationship and peer comradery, the presence of a strong social network of family and friends, and the convenience and efficiency associated with accessing telehealth physical therapy services. Technology served as a facilitator for those who identified value in using the digital tools but was a barrier for those who were dissatisfied with the tool. The program logistics of the group sessions were a barrier for participants who were working, and there was a subset of key informants who did not find value in the coaching sessions. Both findings led to improvements in the program. The findings from this evaluation may be adapted for the development of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change.


A p-value of <0.05 was used for statistical significance, and a ROC AUC score of >0.8 was considered a good result. A cut-off score was defined in an evaluation cohort and subsequently analyzed in an independent validation cohort. In total, 81 PRAME-stained specimens were included. The evaluation cohort included 32 (50%) SSM and 32 (50%) DN, and the mean of PRAME-positive cells/mm2 for the entire lesion was 455.3 (SD 428.2) in SSM and 60.5  in DN. The ROC AUC of PRAME-positive cells of the entire lesion was 0.866, and in the epidermis it was 0.901. The defined cut-off score to distinguish between DN and SSM was 97.67 cells/mm2. In the validation cohort, 16 out of 17 cases (94.1%) were correctly classified by the cut-off score. The computer-aided assessment of PRAME immunostaining is a useful tool in dermatopathology to distinguish between DN and SSM. Lesions with a moderate expression and indifferent morphologic features will remain a challenge for dermatopathologists.PRAME  is a cancer testis antigen that is frequently expressed in melanoma compared to benign melanocytic proliferations and nevi. However, the interpretation of the intensity and distribution of PRAME immunostaining is not standardized a lot, which makes interpretation difficult. PRAME-stained histological slides of superficial spreading melanomas (SSM) and dysplastic nevi (DN) were digitized and analyzed using the digital pathology and image platform QuPath.  For decades, the distinction between dysplastic nevi and melanoma has remained a challenge faced by virtually all practicing dermatopathologists. Histological diagnosis is primarily made with the conventional hematoxylin and eosin (HE) stain through an assessment of the morphological features of the lesion, including pagetoid spread, cytological atypia, dermal mitoses, asymmetry, lack of circumscription, impaired maturation and hypercellularity . Neverthn = 64), the mean of PRAME-positive cells/mm2 in the entire lesion was 455.3 (SD 428.2) in SSM and 60.5 (SD 130.1) in DN. With restriction to the epidermis, the mean was 656.3 (SD 612.9) in SSM and 70.3 (SD 156.8) in DN. The difference in PRAME-positive cells/mm2 between SSM and DN was highly significant , 16 of 17 cases were correctly classified through the predicted cut-off score  was 1106.8 (SD 843.5) for the entire lesion and 13.9  for DN.Overall, 81 PRAME stains of 81 different specimens were analyzed. They included 40 (49.4%) SSM and 41 (50.6%) DN. In the evaluation cohort, 90.6% of the DN were junctional nevi and 9.4% were compound nevi. The mean tumor thickness of the SSM was 0.42 mm (SD 0.2 mm). In the validation cohort, 44.4% of the DN were junctional nevi and 55.6% were compound nevi. The mean tumor thickness of the SSM was 0.66 mm (SD 0.39 mm). Additional clinical features are summarized in 0.001; 2 . This cue 94.1%; . The mea2 as an acceptable threshold of PRAME positivity [CTAs are highly expressed in cancer cells and in non-cancer tissues restricted to the reproductive organs. In particular, PRAME is involved in many cellular processes that are relevant for tumor genesis, such as proliferation, anti-apoptosis and metastasis. Thus, PRAME seems to be a suitable target for the differentiation between benign and malignant melanocytic lesions of the skin. Its value in the diagnosis of neoplastic skin lesions has been evaluated for many different entities, such as melanocytic lesions of the nail , spitzoisitivity . Howeversitivity . Gassenmsitivity . In ordesitivity .2 for melanoma, with a sensitivity of 71.9% and specificity of 87.5%. The cut-off of 10 PRAME-positive cells/mm2, as previously suggested by Olds et al. [2 is a strong indicator for melanoma, with a specificity of >87%, demonstrating that a high PRAME expression in DN occurs rarely. According to the data and as we could observe in our validation cohort, a high PRAME expression is strongly suggestive of melanoma, although melanoma cannot be fully excluded when PRAME expression is low. Considering the involvement of PRAME in tumorigenic processes, we suggest the use of a cut-off value of 100 cells/mm2 for melanoma diagnosis. Furthermore, we did not observe a difference in the ROC AUC between all (baseline) and strong (level 1) PRAME immunoreactive nuclei, indicating that a general immunoreactivity may point to a malignant potential as well as an intense expression of fewer cells, which is in line with a comparably low sensitivity of 71.9% at the cut-off score of 97.67 cells/mm2. Additionally, we tried to evaluate the difference between PRAME expression in the epidermis and the entire lesion. Research was published stating that PRAME stains the intraepidermal component in some nevi with a decreasing gradient towards depth [In this study, we assessed PRAME expression in early invasive SSM and DN and went beyond these previous analyses using a standardized computer-assisted procedure to minimize intra- and inter-observer variability . As DN cs et al. , would eds depth . This obLimitations of this study were the small sample size and the fact that we only included cases in which PRAME was stained as part of the routine histologic diagnosis. Therefore, on the one hand, PRAME expression might have influenced the diagnosis, resulting in a bias. On the other hand, it demonstrates that exclusively borderline lesions were evaluated, which might have biased a clear cut-off between the two cohorts. Finally, the blinding was impaired, as the investigator could recognize the diagnosis of the samples due to the overall morphology.2 should raise a high degree of suspicion for melanoma but not exclude a diagnosis of melanoma in lesions with lower expression levels or an exclusively epidermal expression. Lesions with a moderate PRAME expression and indifferent morphologic features will remain a challenge for dermatopathologists.In conclusion, PRAME immunostaining seems to be a reliable tool to distinguish between DN and SSM, but PRAME expression is on a continuum, and a clear cut-off is difficult to define. Based on our results, a PRAME expression of more than 100 cells/mmn = 64) and between September 2022 and March 2023 for the validation cohort (n = 17). The histological slides were obtained from the archives of the Unit for Dermatohistology, Department of Dermatology, Uniklinikum Erlangen, Germany. Prior to analysis, the slides were reviewed to exclude bleached and artifact-rich specimens. Patients were sampled and information obtained from the clinical and pathologic records.This study was conducted under approval of an independent research ethics committee of the Friedrich-Alexander-University Erlangen-Nuremberg . This retrospective analysis was based on 81 cases, in which PRAME was routinely stained for the classification of SSM and DN between January and August 2022 for the evaluation cohort . A commercially available antibody to PRAME  with a dilution of 1:300 and an incubation time of 36 min was used. Further, Fast Red chromogen for immunohistochemical staining was applied to rule out interference with unspecific cytoplasmic melanin pigment.2 for all annotations in different intensity grades was extracted.All slides were digitized with the NanoZoomer-SQ  at a 40× magnification, with a resolution of 0.23 µm/pixel. The PRAME-stained slides were analyzed with the bioimage analysis software QuPath (version 0.3.2) . The anap-value of <0.05 was used for statistical significance. Additionally, the evaluation cohort was classified through a receiver-operating-characteristic curve (ROC-curve) and the area under the curve (AUC). A ROC AUC score of >0.8 was considered good, and >0.9 was considered to be a very good result [® SPSS Statistics .The evaluation cohort was split according to the diagnosis (SSM versus DN) and compared using the t-test. A two-sided d result . In a ne


Coronary heart disease (CHD) remains the leading cause of death in Australia, with a high residual risk of repeat events in survivors. Secondary prevention therapy is crucial for reducing the risk of both death and other major adverse cardiac events. The National Heart Foundation of Australia has developed a consumer-facing support program called My Heart, My Life (MHML) to address the gap in the secondary prevention of CHD in Australia. The MHML pilot program supplies advice and support for both patients and their caregivers, and it was conducted over 8 months from November 2019 to June 2020.This study aims to describe and examine the implementation of a novel multimodality secondary CHD prevention pilot program called MHML, which was delivered through booklets, text messages, emails, and telephone calls.This pilot study consists of a mixed methods evaluation involving surveys of participants (patients and caregivers) and health professionals, in-depth interviews, and digital communication . This study was performed in people older than 18 years with acute coronary syndrome or angina and their caregivers in 38 Australian hospitals from November 2019 to June 2020 through the National Heart Foundation of Australia web page. The main outcome measures were reach, accessibility, feasibility, barriers, and enablers to implementation of this program.Of the 1004 participants , 60.9% (608/1001) were males, 50.7% (491/967) were aged between 45 and 64 years, 27.4% (276/1004) were from disadvantaged areas, 2.5% (24/946) were from Aboriginal or Torres Strait Islander background, and 16.9% (170/1004) reported English as their second language. The participants (patients and their caregivers) and health professionals reported high satisfaction with the MHML program . Of the 62 participants who took the survey, 88% (55/62) used the text messaging service and reported a very high level of satisfaction. Approximately 94% (58/62) and 89% (55/62) of the participants were satisfied with the quick guide booklets 1 and 2, respectively; 79% (49/62) were satisfied with the monthly email journey and 71% (44/62) were satisfied with the helpline calls. Most participants reported that the MHML program improved preventive behaviors, that is, 73% (45/62) of them reported that they maintained increased physical activity and 84% (52/62) reported that they maintained a healthy diet even after the MHML program.The findings of our pilot study suggest that a multimodal support program, including digital, print, phone, and web-based media, for the secondary prevention of CHD is useful and could be a potential means of providing customized at-scale secondary prevention support for survivors of acute coronary syndrome. Coronary heart disease (CHD) causes the greatest burden of disease and remains the leading cause of death in Australia . The risThe benefits of secondary prevention programs for CHD, which include counselling, education, and exercise components, have been proven to reduce the risk of repeat MACE . AlignedThe MHML program was initiated to complement existing support programs such as cardiac rehabilitation and was designed to improve patients’ access to health information and support Australians during and after their cardiac events to facilitate safer transitions of care and enhanced access to secondary prevention support . This prThe specific objectives of this study were to (1) describe the uptake of the MHML program, including reach and accessibility, (2) describe the characteristics of participants accessing the MHML program, (3) examine and report the implementation of the MHML pilot program with regard to feasibility, (4) provide insight into the acceptability of the patient support journey, and (5) provide information on the barriers and enablers to wide-scale implementation of this program.This study received ethics approval from the University of Sydney Human Research Ethics Committee  for the project title “My Heart, My Life Support Program Pilot Evaluation.”This study had a mixed methods design involving quantitative and qualitative data collection. The term participants refers to patients and their caregivers in this paper.The MHML is a multimodal program, merging existing and new resources, delivered at no cost to participants, as outlined in Print resources were provided through 2 booklets. Part 1: “Your Quick Guide to Heart Attack and Angina,” which was given in the hospital, was designed to provide individualized information upon discharge. The booklet contained a record-keeping tool for documentation of risk factors, nearest cardiac rehabilitation program, driving restrictions, and individual goals. Part 2 “Living Well With Heart Disease: Heart Attack and Angina” was mailed to the enrolled participants only. This booklet contained detailed information on long-term risk factor management, nutrition, physical activity, psychosocial well-being, and returning to pre-event quality of life.The digital resources consisted of 2 components. The first component was a mobile phone text messaging program based on the Heart Foundation grant-in-aid–supported TEXT ME (tobacco exercise and diet messages)  and deliThe enrolled participants also received 2 calls by trained health professionals from the NHFA helpline. The calls provided individualized support and reassurance based on the NHFA’s “six steps to cardiac recovery” resource. The first call, within 2-4 weeks of enrollment, discussed the hospital admission, rehabilitation options, information on risk factors, and navigating the health system. The second phone call at 3 months was to address outstanding information needs. If the first call was unanswered, an SMS text message was sent to allow the participant to return the call at their convenience. The COVID-19 pandemic decreased face-to-face interactions in the hospital and reallocation of resources at NHFA. This reduced the opportunity for promotion and engagement with hospitals and therefore patient and caregiver recruitment and initial delay by 2 weeks in meeting helpline call-timing goals.In this pilot program, 38 Australian hospitals  from divData were collected by the NHFA insights team, which was separate from the MHML implementation team. Participant data were collected at baseline, at 3 months, and toward the end of the pilot study across an 8-month evaluation period. Not all participants completed the 3-month survey, as the evaluation occurred 8 months into onboarding. Surveys comprised questions on acceptability, usefulness, knowledge, behavior change, and usage of intervention components (Table S1 of P<.05). Analytics reports from the TextCare text messaging platform, email journey, and helpline were analyzed, and the feedback log was analyzed according to themes. Thematic analysis was performed to survey open-ended questions and interviews. A results matrix was used to triangulate the different data sources and methods by each of the key evaluation questions. This matrix was used to assess where there were similarities or any differences by data source and by method and enabled the development of overarching key findings.Quantitative data analysis used descriptive statistics. Chi-square goodness-of-fit tests were used to compare the MHML sample with the general population to assess representativeness for various demographic variables , consisting of patients  and caregivers , were enrolled in this pilot study . Most paP<0.001) (P<0.001) than the overall population with CHD in Australia  were males (2 preferred not to answer), while 85.9%  of the caregivers who enrolled were females. The proportion of the male patients in this program is representative of the male hospitalization data, which is higher for CHD, and suggested that the program was well accessed by both men and women. Overall, 27.6% (276/1004) of the patients lived in disadvantaged areas, 2.5% (24/946) were Aboriginal or Torres Strait Islander people, and 16.9% (170/1004) reported English as their second language. The ratio of men to women in this study was similar to that of the national heart disease hospitalized population [P<0.001)  and lessustralia .Overall, 17,820 part 1 booklets were distributed to hospitals to be provided to patients and caregivers, and participants had to complete a web-based enrollment form to receive subsequent components of the program. The conversion rate from booklets provided to actual enrollments was low, as only 1187 part 2 booklets were distributed to the enrolled participants. Most enrollments occurred following a hospital admission , and 26.9% (275/1004) self-registered via the NHFA website.Participants who had successfully completed the web-based registration form reported that web-based registration was simple. Health professionals and helpline staff reported barriers to onboarding, including confidence with technology, web-based form length, unclear information of the registration process, and absence of an email address . Health care staff, participants, and helpline staff reported that enablers may include (1) simplification and shortening of the web-based form, (2) providing feedback or monthly report to health professionals about enrolled patients to help maintain the program’s profile, (3) bedside enrollment by health professionals, and (4) raising awareness among health professionals, patients, and caregivers. The majority  of the health professionals reported that it was realistic to promote this program. The encouragement by health professionals was important to participants and was a key driver for the enrollment noted during participant interviews.Overall, 94% (58/62) of the participants reported a high level of satisfaction with part 1 booklets and 89% (55/62) of them were satisfied with part 2 booklets. Most health professionals  reported that the part 1 booklet assisted with patient education and agreed that it addressed key messages, provided meaningful and helpful content, had appropriate language, and was well-designed . The harApproximately 73% (733/1004) of the participants commenced the text messaging service, with 9% (90/1004) opting out. Reasons for opting out included feeling that messages were repetitive and were common sense. The majority  continued receiving messages until the end of the pilot period. Of those who responded to the survey, 88% (55/62) used the text messaging service and reported a very high level of satisfaction . The strOutbound calls were provided to 978 participants, with 1691 calls made. Half of the participants who partook in the 3-month survey reported using this service, with 68% (42/62) reporting that it was helpful . The aveThe data of email opening rates and clicking on content showed that there was good engagement of 964 participants with the email journey. Most continued on the journey, with only 11 participants opting out. Engagement rates in the first 2 emails were higher than those in subsequent emails. The MHML open rate  and click-to-open rate  . All of them (62/62) reported being satisfied with the text message journey: 94% (58/62) and 89% (55/62) were satisfied with booklets 1 and 2, respectively; 79% (49/62) were satisfied with the monthly email journey; and 71% (44/62) were satisfied with the helpline calls. . All intThe self-assessed knowledge and confidence of the participants to manage their heart conditions were gauged at baseline, at the 3-month survey, and during interviews. Many participants reported trying to implement lifestyle behavior changes after joining the MHML, and a large proportion reported maintaining these changes after the program, for example, 73% (45/62) maintained increased physical activity and 84% (52/62) maintained a healthy diet .MHML is a unique health care program delivered by the NHFA. Other organizations, including the British Heart Foundation and American Heart Association, promote telephone hotlines, web-based forums, and patient information pamphlets; however, a national, individualized, and multimodal program for CHD secondary prevention is yet to be implemented ,11. EconThe pilot MHML program was well-received by participants and health professionals, the majority of whom reported that the program was easy to use . Of note, much of the implementation of this pilot program was during the COVID-19 pandemic, thereby demonstrating the utility of alternative methods of support to patients with CHD at an otherwise vulnerable time point. The at-scale delivery of secondary prevention programs is challenging, and despite the knowledge that these programs are effective, little improvement has been made across the years in achieving comprehensive engagement of survivors of ACS in secondary prevention programs. The strengths of this program include the multimodal delivery of cardiac information by a centralized and respected organization, thereby supplementing existing care while encouraging self-management in secondary prevention.Self-management strategies often lead to sustained behavioral change, and supporting patients on this journey to empower them is crucial . MultiplWith regard to the feasibility of this program, there was overall satisfaction and acceptability in the feedback from health care professionals. The benefits of the MHML program were clearly expressed with the primary concern of implementation related to staffing of the service.The participants found most aspects of the MHML program acceptable and helpful. Of note, they particularly valued the text messaging program, which has previously shown to alter cardiovascular outcomes in randomized controlled studies . Given tGiven the high levels of satisfaction regarding this pilot program, future directions should include a broader rollout of the MHML program. In particular, additional tools should be provided to support patient recovery , specific resources should be provided for patients of Aboriginal and Torres Strait Islander descent in addition to those from culturally and linguistically diverse backgrounds, and the program should be expanded to other hospital locations and include other types of cardiac conditions such as heart failure.We acknowledge that the participants of the evaluation may have been more engaged with the program than those who had not engaged with the program. The invitation to participate in the surveys was distributed by email; therefore, participants who had responded may have been more skilled with technology than those who had not responded.The NHFA MHML pilot program was widely accepted by participants and health professionals. The NHFA is dedicated to improving recovery after a cardiac event and aims to improve and expand MHML by using evaluation findings. Future evaluations will consider more quantitative and clinical outcomes such as medication adherence and risk factor management to have an impact on the rates of unplanned rehospitalizations and the quality of life of participants.


There are very few studies that have compared the short-term outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Among short-term outcomes, hospital readmission after these procedures is an area for quality enhancement and cost reduction. In this study, we compared 30-day readmission rates after LSG and LRYGB through analyzing a nationalized dataset. In addition, we identified the reasons of readmission.The current study was a retrospective analysis of data from National Surgical Quality Improvement Program (NSQIP) All adult patients, ≥ 18 years of age and who had LSG or LRYGB during 2014 to 2019 were included. Current Procedural Terminology (CPT) codes were used to identify the procedures. Multivariate logistic regressions were used to calculate propensity score adjusted odds ratios (ORs) for all cause 30-day re-admissions.P < 0.001). The odds of 30-day readmissions were significantly higher among LRYGB group compared to LSG group . In addition, variables such as age, chronic obstructive pulmonary disease, hypertension, bleeding disorders, blood urea nitrogen, SGOT, alkaline phosphatase, hematocrit, and operation time were significantly predicting readmission rates.There were 109,900 patients who underwent laparoscopic bariatric surgeries (67.5% LSG and 32.5% LRYGB). Readmissions were reported in 4168 (3.8%) of the patients and were more common among RYGB recipients compared to LSG (5.6% versus 2.9%, Readmission rates were significantly higher among those receiving LRYGB, compared to LSG. Readmission was also affected by many patient factors. The factors could help patients and providers to make informed decisions for selecting appropriate procedures. The World Health Organization considers obesity to be a major public health challenge . AccordiThere has been limited success in improving obesity-related comorbidities through non-operative measures such as increased physical activity, dietary modification, and behavioral interventions . BariatrBariatric surgeries have improved significantly over the past decades. Conventional bariatric procedures such as vertical and horizontal gastroplasty and jejunoileal bypass are not performed currently due to several associated complications . For theAlthough LSG is associated with fewer technical challenges compared to LRYGB , very feThe current study was a retrospective analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database collected during the years 2014 to 2019. All patients who underwent LSG or LRYGB during this period and who were ≥ 18 years of age were selected from the NSQIP database. The NSQIP includes data from greater than 400 surgical centers within the USA. This includes urban academic hospitals to small community practice centers. As a third party collecting independent data from each center, the NSQIP has provided validated and reliable measurements of various health quality metrics for research purposes .Current Procedural Terminology (CPT) code 43,775 was used to identify LSG, while codes 43,644 and 43,645 were used to identify LRYGB from the NSQIP Participant User Files ) age was 44.0  years and median (IQR) BMI was 43.9  kg/mP < 0.01), non-insulin dependent diabetes , COPD , and hypertension  were higher among those who underwent LRYBG, while smoking history , congestive heart failure , dialysis , and chronic steroid use  were higher among those who underwent LSG. The distribution of comorbidities between LSG and LRYGB groups are shown in Table P < 0.01; non-insulin dependent 19.4% versus 16.4%, P < 0.01) and hypertension . In the matched cohort, the LSG group compared to the LRYGB group had a higher dialysis  and chronic steroid use . Table  LRYGB comorbidities such as insulin-dependent diabetes , compared to the LSG group, without standardization  [Given the significant number of potential confounders, understanding the independent impact of any bariatric procedure  could be challenging. To overcome this issue, we used a strict propensity score match, which was able to adequately control for confounding variables. Our data showed that even after propensity score matching, the rates of 30-day readmissions were significantly higher after LRYGB, compared to LSG. This suggests that LRYGB is independently associated with increased readmission rates, while patients undergoing LSG are less likely to be readmitted. This finding is consistent with a recent study of New York statewide data showing a significantly higher readmission rate of 6.14% after LRYGB, compared to 4.33% after LSG . Using N < 0.01) . However < 0.01) , 36. How < 0.01) . However < 0.01) , 38.P < 0.01) and were more at risk for cardiac complications as indicated by their higher rates of antihypertensive medication use . These results are consistent with those reported by Spaniolas et al., who showed a higher prevalence of diabetes among LRYGB patients, compared to LSG  [Our retrospective analysis demonstrated that patients undergoing LRYGB have a higher rate of readmission compared to those who underwent LSG, even after propensity score matching. One possible reason could be that the two groups were differing with respect to unmeasured confounders. This may have resulted in apparently higher rates of readmission for those who had higher comorbidity burden at baseline, for example, tobacco user with diabetes who underwent LRYGB versus patients with obesity with mild hypertension who underwent LSG. Notably, the LRYGB group had greater prevalence of insulin-dependent diabetes  .We used a large-scale database such as NSQIP which has strengthened our study. We could analyze data from a large sample of bariatric surgery patients, and this greatly improved the accuracy of our estimates. This database includes both community and academic hospitals across the USA, thereby increasing the generalizability of our findings. In addition, a large number of perioperative variables were available for analysis. Thus, the NSQIP database provides clear benefits of power and heterogeneity of practice, type, and volume, offering one of the best possible representations of bariatric surgery at the national level.Our study has some limitations. We conducted a retrospective analysis of NSQIP database. Our data included only those hospitals that participated in NSQIP. This could have resulted in some selection bias. NSQIP is an administrative database and not bariatric specific. Therefore, only those variables that were collected by NSQIP were available for analysis. NSQIP does not have data on providers or volume of procedures occurring in the hospitals. This could have affected our findings on readmissions as readmission is associated with factors such as bariatric accreditation status and volume of procedures , 40. ImpUsing propensity score matched analysis we found that 30-day readmission were significantly higher among those receiving LRYGB, compared to LSG. In addition to the procedure type, readmission is also affected by many patient factors. These factors should be discussed by both patients and providers while selecting appropriate procedures. Our findings should be confirmed by future large-scale experimental studies.