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

Background: Heart failure (HF) is a chronic, progressive medical condition. Evidence suggests that guideline-directed medical therapy improves both morbidity and mortality in patients with HF with reduced ejection fraction when properly optimized. Unfortunately, many patients do not receive optimized therapy, highlighting the need to optimize clinicians' methods to more effectively and efficiently initiate and titrate medical therapy.

Methods: This single-center, retrospective study evaluated the rates of drug interventions prompted by the home telehealth monitoring program for veterans with HF with reduced ejection fraction. Rates of drug interventions were evaluated among those who enrolled and those who did not enroll in the program.

Results: There were 20 drug-related interventions in the home telehealth group compared with 11 interventions for the control group. One HF-related hospitalization occurred in the home telehealth program group compared with 6 in the control group.

Conclusions: This study demonstrates the potential of home telehealth to optimize veterans' medication regimens and to reduce HF-related hospitalizations. It also provides an additional catalyst to further develop home telehealth services specifically targeted at drug therapy initiation and optimization in patients with HF with reduced ejection fraction.

Background: Long-term use of inhaled corticosteroids (ICSs) is associated with several potential adverse effects. While patients unlikely to benefit should stop ICS use, abrupt discontinuation may result in an increased risk of chronic obstructive pulmonary disease (COPD) exacerbation. Stepwise tapering may reduce this risk but data are limited, and there is no consensus on the likelihood of COPD exacerbations following ICS discontinuation. The North Texas Veterans Affairs Health Care System conducted a single center, retrospective cohort study to evaluate the rate of COPD exacerbations following the discontinuation of ICS therapy using different schedules of discontinuation.

Methods: Data were collected from the electronic health records of patients aged ≥ 40 years with a diagnosis of COPD who were on a stable dose of an ICS for ≥ 1 year that was subsequently discontinued with a last documented fill date between January 10, 2021 and September 1, 2021. Eligible patients were followed for COPD exacerbations that resulted in hospitalization until November 1, 2022. Descriptive statistics were used to evaluate characteristics of patients who experienced an exacerbation.

Results: Seventy-five patients were included: 5 (7%) experienced an exacerbation following ICS discontinuation. Age, sex, race, and ethnicity were similar for those patients who did vs did not have an exacerbation. Unexpectedly, the mean baseline eosinophil count for patients with an exacerbation was 92 cells/μL compared with 227.4 cells/μL for those without an exacerbation. Nine patients had their ICS tapered gradually, and none of them experienced an exacerbation.

Conclusions: Study findings suggest that there is a relatively low risk of COPD exacerbation following ICS discontinuation, regardless of whether a taper was performed. This result may indicate that it is reasonable to abruptly discontinue ICS in eligible patients.

Background: Semaglutide and liraglutide are glucagon-like peptide 1 receptor agonists (GLP-1 RAs) approved by the US Food and Drug Administration for patients with type II diabetes mellitus (T2DM). Patients with T2DM treated with liraglutide at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) were converted to semaglutide. The primary objective was to assess changes in glycemic control and cost savings that resulted from this conversion.

Methods: We conducted a retrospective chart review of veterans without retinopathy treated at MEDVAMC between March 1, 2021, and November 30, 2021, who were converted from liraglutide 0.6 mg and 1.2 mg daily to semaglutide 0.25 mg weekly (titrated to 0.5 mg weekly after 4 weeks). We compared hemoglobin A_1c (HbA_1c) values at baseline and 3 to 12 months following conversion to assess glycemic control. Cost savings were evaluated using outpatient pharmacy data.

Results: During the study, 411 patients were converted from liraglutide to semaglutide; 49 additional patients met the criteria for clinician education, and 14 were converted as a result. In total, 304 patients met the criteria for inclusion. At baseline, patients' mean (SD) levels included: HbA_1c, 8.1% (1.5); blood glucose, 187.4 (44.2) mg/dL; and body weight, 112.9 (23.0) kg. Three to 12 months postconversion, patients' mean (SD) HbA_1c significantly decreased to 7.6% (1.4) (P < .001), blood glucose decreased to 172.6 (39.0) mg/dL (P < .001), and body weight decreased to 105.2 (32.3) kg (P < .001). Cost savings exceeding $400,000 resulted from liraglutide to semaglutide conversion.

Conclusions: Conversion of liraglutide to semaglutide led to significant HbA_1c decrease and weight loss and resulted in minimal changes to patients' antihyperglycemic regimen. Common adverse effects included hypoglycemia and gastrointestinal intolerance. Due to the low conversion rate of liraglutide to semaglutide following education, a more effective method of education for clinicians to promote teleretinal imaging before conversion is warranted. Lastly, although the semaglutide cost savings initiative at MEDVAMC resulted in significant savings for the institution, a full cost-effective analysis is needed for further conclusion.

Background: The 2017 American College of Cardiology/American Heart Association blood pressure guideline recommends chlorthalidone as the preferred thiazide diuretic. We aimed to better understand thiazide prescribing patterns within the US Department of Veterans Affairs (VA).

Methods: A retrospective analysis was conducted of patients with a prescription for hydrochlorothiazide (HCTZ), chlorthalidone, indapamide, or any combination products containing these from January 1, 2016, to January 21, 2022. The primary objective was to determine the utilization rates of each thiazide in the active cohort, assessed via χ² test with Bonferroni correction. Secondary objectives included concomitant potassium or magnesium supplementation, blood pressure rates and control, and thiazide use from January 1, 2016, to December 31, 2021.

Results: Of 628,994 active thiazide prescriptions, utilization rates differed significantly between thiazide groups (P < .001). Rates for HCTZ, chlorthalidone, and indapamide were 84.6%, 14.9%, and 0.5%, respectively. HCTZ use decreased from 90.2% to 83.5% (P < .001) and chlorthalidone use increased from 9.3% to 16.0% (P < .001). Between thiazide groups, rates of blood pressure control were not significantly different (P = .58). Potassium or magnesium supplementation was significantly different between groups (P < .001). The highest concomitant supplementation was with indapamide followed by chlorthalidone and HCTZ with rates of 27.1%, 22.6%, and 12.4%, respectively.

Conclusions: Despite guideline recommendations for chlorthalidone, HCTZ is the most prescribed thiazide diuretic within the VA. However, there was a significant trend toward increased chlorthalidone prescribing from 2016 to 2021. Application of these data may guide further research to increase guideline-recommended therapy.

Background: Antimicrobial stewardship programs (ASPs) are vital to improving patient safety and ensuring quality of care but are often underresourced, limiting their effectiveness and reach. While barriers to ASP success have been well documented, approaches to address these barriers with limited resources are needed. Stewardship networks and collaboratives have emerged as possible solutions. In January 2020, 5 US Department of Veterans Affairs facilities created a regional ASP collaborative. In this article, we describe the impact of this collaborative on the productivity of the facilities' ASPs.

Methods: ASP annual reports for each of the 5 facilities provided retrospective data. Reports from fiscal year (FY) 2019 and reports from FY 2020-2022 were reviewed. Staffing, inpatient and outpatient stewardship reporting, individual and collaborative initiatives, and publications data were collected to measure productivity. Yearly results were trended for each facility and for the region. Additionally, the COVID-19 antibiotic use dashboard and upper respiratory infection dashboard were used to review the impact of initiatives on antibiotic prescribing during the collaborative.

Results: Regular reporting of outpatient metrics increased; 27% of measures showed improvement in 2019 and increased to 60% in 2022. For all 5 facilities, ASP initiatives increased from 33 in 2019 to 41 in 2022 (24% increase) with a corresponding increase in collaborative initiatives from 0 to 6. Likewise, publications increased from 2 in 2019 to 17 in 2022 (750% increase). Rates of reporting and improvement in inpatient metrics did not change significantly.

Conclusions: The ASP collaborative aided in efficiency and productivity within the region by sharing improvement practices, distributing workload for initiatives, and increasing publications.

Background: Patients on intensive insulin regimens are encouraged to self-monitor blood glucose (SMBG) to optimize their therapy. Clinical pharmacist practitioners (CPPs) use SMBG data to adjust diabetes medications; however, collecting SMBG data from patients is seen anecdotally as time intensive.

Methods: CPPs involved in diabetes management on primary care teams at the Boise Veterans Affairs Medical Center in Idaho were asked to estimate and record the following: SMBG data collection method, time spent collecting data, extra time spent documenting or formatting SMBG readings, total patient visit time, and visit type. For total patient visit time, pharmacists were asked to estimate only time spent discussing diabetes care and collecting SMBG data. Data were collected for 1 week using a standardized spreadsheet distributed to 24 CPPs.

Results: Eight pharmacists provided data from 120 patient encounters. For all encounters, the mean time spent collecting SMBG data was 3.3 minutes, and completing additional documentation/formatting was 1.3 minutes for a total of 4.6 minutes. Patient visits lasted a mean 20.1 minutes; 16% was spent on data collection and 6% on documentation and formatting.

Conclusions: At the Boise Veterans Affairs Medical Center, CPPs spend relatively little time per patient collecting SMBG data for clinical use. However, this time can be substantial when multiplied over several patient encounters. Opportunities exist to increase efficiency in SMBG data collection and documentation.

Background: Opioid use disorder is a significant cause of morbidity, mortality, and health care costs. A transitional pain service (TPS) approach to perioperative pain management has been shown to reduce opioid use among patients undergoing orthopedic joint surgery. However, whether TPS also leads to lower health care use and costs is unknown.

Methods: We designed this study to estimate the effect of TPS implementation relative to standard care on health care use and associated costs of care following orthopedic surgery. We evaluated postoperative health care use and costs for patients who underwent orthopedic joint surgery at 6 US Department of Veterans Affairs medical centers (VAMCs) between 2018 and 2019 using difference-in-differences analysis. Patients enrolled in the TPS at the Salt Lake City VAMC were matched to control patients undergoing the same surgeries at 5 different VAMCs without a TPS. We stratified patients based on history of preoperative opioid use into chronic opioid use (COU) and nonopioid use (NOU) groups and analyzed them separately.

Results: For NOU patients, TPS was associated with a mean increase in the number of outpatient visits (6.9 visits; P < .001), no change in outpatient costs, and a mean decrease in inpatient costs (-$12,170; P = .02) during the 1-year follow-up period. TPS was not found to increase health care use or costs for COU patients.

Conclusions: Although TPS led to an increase in outpatient visits for NOU patients, there was no increase in outpatient costs and a decrease in inpatient costs after orthopedic surgery. Further, there was no added cost for managing COU patients with a TPS. These findings suggest that TPS can be implemented to reduce opioid use following joint surgery without increasing health care costs.

Background: Although the management of chronic kidney disease (CKD) has changed considerably in US adults, it is uncertain whether the burden, risk factors, and temporal trends of CKD are similar regarding prior military service.

Methods: This observational study used National Health and Nutrition Examination Survey data to quantify the association between CKD and military service in a generalizable sample of US adults between 1999 and 2018.

Results: The respective frequencies (standard error [SE]) of CKD and military service were 15.2% (0.3) and 11.5% (0.3). The proportion (SE) with CKD was significantly higher among those with prior MS vs the overall population (22.7% [0.7] vs 15.2% [0.3]; P < .001). Within the military service population, the proportion (SE) with CKD differed by era: 1999 to 2002, 18.9% (1.1); 2003 to 2006, 24.9% (1.5); 2007 to 2010, 22.3% (1.5); 2011 to 2014, 24.3% (1.7); and 2015 to 2018, 24.0% (1.8) (P = .02). Following adjustment for age, sex, and race and ethnicity, prior military service was associated (P < .05) with a higher likelihood of CKD (adjusted odds ratio, 1.17; 95% CI 1.06-1.28). Adjusted associations of CKD differed in groups with and without military service for the 40 to 64 years age group, ≥ 65 years age group, female sex, and family poverty (P < .05 vs variable-specific reference category).

Conclusions: Military service is associated with a higher likelihood of CKD in US adults. Risk factors for CKD differed among many subgroups both with and without military service history. Future research is needed to better determine whether military service constitutes a unique risk factor for CKD.