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

Background: The Epilepsy Centers of Excellence (ECoE) is a network of facilities within the Veterans Health Administration that evaluates and treats veterans with epilepsy and seizure disorders. This article outlines how the COVID-19 pandemic impacted ECoE services and recovery.

Methods: Directors of 17 ECoEs were surveyed 4 times between May 2020 and July 2022 on 5 domains: functioning of outpatient epilepsy clinics, outpatient electroencephalogram, epilepsy monitoring unit, anticipated permanent operational changes, and utility of national and local recommendations. Data on the spread of COVID-19 and administrative workload data were compared with the availability of epilepsy services.

Results: There was an increase in in-person outpatient visits from May 2020 (1 of 13 sites) to June 2022 (all 16 sites). Similar increases were also observed for outpatient electroencephalogram from 4 of 13 sites and subsequently all 16 sites, and for epilepsy monitoring unit from 1 of 12 sites to 11 of 16 sites. The spread of COVID-19 did not correlate with the availability of services. Respondents predicted telehealth would be a permanent change.

Conclusions: Comprehensive ECoEs within the Veterans Health Administration increased services during the COVID-19 pandemic without demonstrating an association to the disease's spread.

Background: Patients with diabetes have traditionally been required to use fingerstick testing to self-monitor their glucose levels. However, continuous glucose monitors (CGMs) collect glucose readings throughout the day and display daily trends, which allow clinicians to individualize treatment to achieve hemoglobin A_1c (HbA_1c) goals and simplify medication regimens. While studies have shown that CGMs improve HbA_1c levels compared to fingerstick testing, this research has focused on type 1 diabetes and excluded veterans and patients on insulin therapy.

Methods: This retrospective chart review used a crossover, self-controlled design conducted at the Veterans Affairs Sioux Falls Health Care System. Veterans with an active CGM prescription were included. The primary endpoint compared the change in HbA_1c before and after initiation of a CGM.

Results: The mean baseline HbA_1c for the 150 veterans included in this study was 8.6%. The change in HbA_1c before CGM use was 0.003 and change in HbA_1c after CGM use was -0.971. The primary endpoint of difference in HbA_1c associated with CGM use was -0.969 (P = .0001). The overall mean change in total daily doses of insulin was -22 units. Subgroup analysis of change in HbA_1c after CGM use by prescriber type was -0.97 for endocrinology, -0.7 for pharmacy, and -1.23 for primary care practitioners. The overall average HbA_1c post-CGM use was similar across all prescriber types at 7.64%.

Conclusions: This study found veterans with type 2 diabetes and on insulin therapy demonstrated a significant reduction in HbA_1c with CGM use compared with their baseline fingerstick monitoring. Use of a CGM may be beneficial in patients who require a reduction in HbA_1c by allowing more precise adjustments to medications to optimize therapy.

Background: Guidelines recommend a low-density lipoprotein cholesterol (LDL-C) goal of < 70 mg/dL for patients with very high-risk atherosclerotic cardiovascular disease (ASCVD). While alirocumab monotherapy and ezetimibe plus statin therapy have both shown efficacy in independently reducing LDL-C, a direct comparison has not been conducted.

Methods: A retrospective chart review at the Veterans Affairs Sioux Falls Health Care System compared 20 patients with a history of ASCVD events who received alirocumab monotherapy to 60 patients receiving ezetimibe plus statin therapy. The primary endpoint was incidence of reaching the < 70 mg/dL LDL-C goal after 4 to 12 weeks, 13 to 24 weeks, and 25 to 52 weeks.

Results: Fourteen patients (70%) in the alirocumab monotherapy group reached the LDL-C goal (< 70 mg/dL) compared with 34 patients (57%) in the ezetimibe plus statin group (P = .29). In both groups, the goal was most frequently achieved in 25 to 52 weeks.

Conclusions: In a small population of veterans with ASCVD, there was no significant difference between the 2 treatment groups in LDL-C reduction or in several secondary endpoints, including percentage change in high-density lipoprotein and triglycerides, ASCVD events, and adverse events leading to treatment discontinuation. However, a statistically significant difference in percentage reduction in LDL-C and total cholesterol was found favoring alirocumab monotherapy.

Background: The US Department of Veterans Affairs (VA) is committed to conducting research that improves the health and quality of life of veterans. Mentorship is vital for developing and advancing a novice VA investigator's research agenda; however, there are several barriers to effective research mentorship.

Observations: The VA Clinical Research Mentorship Program was developed to assist clinician investigators with writing and submitting competitive grant applications. The program offers group and individualized consultation services utilizing the expertise of experienced investigators/faculty mentors, peer mentors, and other research staff. Since its inception in 2015, 35 clinicians have enrolled. Program mentees have submitted 33 grant proposals, with 19 approved for funding. Among participants who responded to a program evaluation survey, 17 reported (89%) that the meetings were an effective use of their time, 17 reported (89%) that the program increased their work satisfaction, and 13 reported (68%) that the program reduced clinician burnout.

Conclusions: A group-based research mentorship program was positively viewed by participants, proved to be successful in helping mentees obtain funding for research, and had an impact on increasing participants' work satisfaction and reducing levels of burnout.

Background: Antibiotic stewardship programs (ASPs) are multidisciplinary teams that optimize anti-infective use across health systems. The Veterans Health Administration mandates all facilities to implement ASPs and requires the development of ASP collaboratives in its regional Veterans Integrated Service Networks (VISNs).

Observations: The Veterans Affairs Sunshine Healthcare Network (VISN 8) serves > 1.5 million veterans across Florida, South Georgia, Puerto Rico, and the US Virgin Islands. Established in 2015, the VISN 8 ASP workgroup, serves as a model for ASP VISN collaboratives and includes ASP champions from each Veterans Affairs medical center within VISN 8 and meets monthly to review formulary issues, ongoing initiatives, antimicrobial use metrics, and other related topics. The VISN collaborative structure facilitates multisite quality initiatives, such as the implementation of area under the curve (AUC)-guided vancomycin dosing across 4 health care systems within VISN 8. AUC-guided dosing led to decreased rates of acute kidney injury compared with trough-based dosing (2.4% vs 10.4%) and the quality assurance evaluation identified best practices that could be disseminated across the VISN.

Conclusions: The VISN 8 ASP workgroup exemplifies how ASP champions can work together to solve common issues, complete tasks more efficiently, and impact large veteran populations. ASP collaboratives can leverage their collective size to complete robust multisite quality assurance evaluations. Expansion of the ASP collaborative model further highlights the Veterans Health Administration as a nationwide leader in ASP best practices.

Background: Home health agencies (HHAs) provide vital community-based services for older adults. Under-resourced HHAs that are disconnected from broader community emergency planning efforts may struggle to maintain services during emergencies. As climate-related disasters become more prevalent, HHA services are increasingly at risk, and policymakers have focused on the services they provide to older adults. This study explores the relationships between the Veterans Health Administration (VHA) and contracted HHAs to identify opportunities to extend VHA emergency resources to HHAs and staff to assist them during disasters.

Methods: We interviewed 19 stakeholders from 6 Veterans Affairs medical centers. Data were analyzed through rapid qualitative analysis.

Results: VHA and HHA staff focused primarily on their disaster response during emergencies with little knowledge of each other's protocols. VHA emergency managers lacked direct relationships with staff overseeing HHAs but had strong internal partnerships with clinicians and were knowledgeable about the needs of veterans who were disabled and homebound. VHA staff demonstrated an interest in partnering with HHAs to identify resources that could be shared during emergencies.

Conclusions: Creating a pipeline of support through existing relationships and resources has the potential to strengthen VHA protections for older adults during emergencies, help them age safely in place, and provide a model for other health systems to collaborate with community-based practitioners.