Federal practitioner : for the health care professionals of the VA, DoD, and PHS最新文献

Background: In May 2020, the US Food and Drug Administration (FDA) asked 5 pharmaceutical companies to voluntarily recall some formulations of metformin due to contamination. This observational study sought to provide insight changes in hemoglobin A_1c (HbA_1c) levels when veterans switched to alternative antihyperglycemic agents following the recall.

Methods: This study included veterans aged ≥ 18 years with type 2 diabetes who were receiving health care from Veterans Integrated Service Network 6 and had an active metformin sustained-action (SA) prescription as of June 1, 2020. This observational study used a complex random-effects within-between model to evaluate the impact that the recall had on HbA_1c levels as patients transitioned from metformin SA to an alternative antihyperglycemic agent (dipeptidyl-peptidase-4 inhibitor; glitazone; glucagon-like peptide-1 [GLP-1] agonist; sodium-glucose cotransporter-2 [SGLT-2] inhibitor; long-acting, rapid-acting, and mixed insulin formulations; immediate-release metformin, or sulfonylurea). This model identified individual-level (within patient) changes and changes between groups of patients that occurred during the year following the recall.

Results: A total of 9130 veterans were included. GLP-1 agonists were associated with a substantial decrease in HbA_1c levels for patients and a moderate increase between patients (P < .001). SGLT-2 inhibitors were associated with a notable decrease in HbA_1c levels for patients (P < .001). Insulin use was associated with increased HbA_1c levels, but only between patients. Long-acting insulin and mixed insulin demonstrated marked increases between patients (P < .001).

Conclusions: This study demonstrated that following an FDA recall, newer diabetes medications lowered HbA_1c levels compared with metformin SA. Additional registry research is needed to examine HbA_1c trends over time as related to medication therapy and determine long-term complications within the registry population.

Background: Women veterans represent a growing number of veterans with limb loss who receive Veterans Health Administration treatment. This study surveyed a large sample of veterans about their satisfaction with prosthetic-related care and sought to understand how women veterans with limb loss rate their satisfaction with prostheses and care.

Methods: We conducted a cross-sectional, mixed-mode survey of 46,614 veterans with major upper or lower limb amputation or partial foot amputation to assess amputation type, prosthesis use intensity, satisfaction with prostheses and services, and quality of life. We conducted a descriptive analysis and compared responses for individuals who self-identified as men and women. χ² tests determined significant differences in percentage calculations and t tests determined significant differences in means across gender.

Results: A total of 4981 respondents completed the survey, yielding a 10.7% raw response rate. Most respondents identified as men (83%) and White (77%). The mean age for men was 67 years while the mean age for women was 58 years. Women respondents were less likely to have diabetes or report their most recent amputation resulting from diabetes. Women were more likely to report not using a prosthesis, to use prostheses less intensely, and to have lower overall satisfaction, including lower satisfaction with prosthesis appearance, usefulness, reliability, and comfort. Men were more likely to be satisfied with prosthesis training and problem discussion. There were no differences in quality of life rating between women and men.

Conclusions: The findings of this study reflect previous research indicating that women tend to be less satisfied with prostheses. The results also support recent findings that women veterans have different needs regarding prosthesis design and related care. This study is the largest sample of surveyed veterans with limb loss to date. Though the findings suggest veterans are generally happy with prosthetic related services, they point to several areas where their experiences with services or prostheses can be improved.

Background: In 2011, the Veterans Health Administration (VHA) undertook multidisciplinary efforts to improve care for patients with nonhealing foot ulcers and reduce leg amputation rates. This article examines the impact of interdisciplinary care for amputation prevention in the VHA.

Methods: The VHA patient population was characterized using internal registries. Texas hospital admission data were used to identify sex and zip-code matched cohorts. VHA provided data on national and local frequencies of various amputations and the number of patients with diabetes.

Results: Compared to matched nonveteran patients, veterans treated at VHA hospitals were older and more often self-identified as Black. They also had significantly higher rates of diabetes, chronic kidney disease, and systolic heart failure. A decrease from 160 to 66 amputations per 100,000 was seen from 2012 to 2017 (a 60% reduction) after implementing interdisciplinary care. Several evidence-directed practices were implemented during the study period. The proportion of angiograms for foot ulcers or gangrene increased from 28.9% to 90.9%.

Conclusions: Interdisciplinary care can significantly reduce leg amputation rates. This reduction does not seem dependent on a particular model for providing inpatient care.

Background: About 1 in 4 veterans have diabetes, and many also have chronic kidney disease (CKD). Empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, is approved for the treatment of diabetes. The purpose of this study was to evaluate the effectiveness of empagliflozin on hemoglobin A_1c (HbA_1c) in patients with CKD.

Methods: A retrospective chart review evaluated patients that had a type 2 diabetes diagnosis and stage 3 CKD prescribed empagliflozin for diabetes management between January 1, 2015, and October 1, 2022. Patient demographics, medication, HbA_1c levels, and other data were collected from a random sample of 100 patients from 1771 potential study subjects.

Results: There was no statistically significant difference in changes in HbA_1c levels between those with stage 3 and stage 3b diabetes CKD who were taking empagliflozin (P = .51). Within each group, there were significant statistical differences in changes in HbA_1c for patients with stage 3a (P < .05) and stage 3b (P = .02). Patients with stage 3a had a reduction in HbA_1c of 0.65% and the stage 3b grow had a 0.48% reduction. There was a statistically significant weight change for patients in the stage 3a group (P < .05). Statistically significant differences were found in systolic (P = .003) and diastolic (P = .04) blood pressure for the stage 3a CKD group only. The most common adverse effects leading to discontinuation of empagliflozin were dizziness, increased incidence of urinary tract infections, and rash.

Conclusions: Empagliflozin is a favorable option for reducing HbA_1c levels in patients with diabetes and CKD.