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

Background: Dalbavancin and oritavancin are long-acting lipoglycopeptides frequently used off-label to avoid outpatient parenteral antimicrobial therapy or placement of a central line at hospital discharge for patients with infections. Although dalbavancin and oritavancin have higher acquisition costs compared with commonly used antibiotics, such as vancomycin and daptomycin, they may reduce overall cost of health care.

Methods: This single-center, retrospective, cost-minimization analysis compared treatment with oritavancin and dalbavancin vs vancomycin and daptomycin. Adult patients treated with oritavancin or dalbavancin between September 2017 and November 2022 were matched by indication to patients who received vancomycin or daptomycin. Costs were calculated using a decision tree base model.

Results: Fifty-five patients were included in the analysis: 22 received oritavancin, 15 received dalbavancin, 10 received vancomycin, and 8 received daptomycin. The mean cost of therapy per patient receiving oritavancin, dalbavancin, vancomycin, and daptomycin was $35,630, $59,612, $73,333, and $73,708, respectively.

Conclusions: The cost of using oritavancin and dalbavancin was lower than that of vancomycin and daptomycin, especially for osteomyelitis. As safety and effectiveness data continue to emerge, the use of long-acting lipoglycopeptides appears to be an increasingly attractive alternative to traditional outpatient antimicrobial therapy.

Background: The COVID-19 pandemic changed the education and training experiences of health care students. Behavioral health trainees were particularly impacted. As a result of the pandemic, psychologists and social workers received minimal opportunities for administering in-person care and establishing rapport with patients as they adjusted to virtual or remote workplace settings. This study sought to examine the impact of the COVID-19 pandemic on the clinical experiences of behavioral health trainees at US Department of Veterans Affairs (VA) health care facilities.

Methods: This study analyzed psychology and social work responses to the national VA Trainee Satisfaction Survey, including responses before and during the pandemic. Quantitative (bivariate logistic regression) and qualitative content analyses were completed to determine changes in training satisfaction and likelihood a trainee would consider the VA for future employment.

Results: Behavioral health trainees who reported being satisfied or very satisfied (vs those reporting being dissatisfied or very dissatisfied) dropped from 94.8% prepandemic to 93.2% during the pandemic (n = 1555) (P = .04; 95% CI, -3.10 to -0.08). Trainee dissatisfaction centered on the onboarding process, an inadequate number of workspaces and computers, and perceptions of insufficient support in the work environment. While satisfaction decreased, the reported likelihood that behavioral health trainees would consider future employment with the VA was not impacted.

Conclusions: Understanding the VA trainee experience is important for identifying how to improve behavioral health care professional education and training. This study suggests potential areas of concern that can be addressed during future public health emergencies.

Background: Chronic obstructive pulmonary disease (COPD) is underdiagnosed and most diagnoses occur when the disease is advanced, which is associated with worse outcomes. Veterans have a higher prevalence of COPD compared to nonveterans, but some veterans are unlikely to report early symptoms of COPD and primary care practitioners (PCPs) do not routinely ask high-risk patients (aged 50-80 years with a smoking history ≥ 20 pack years) if they have symptoms. There is a pressing need for innovative methods to diagnose COPD earlier in its course.

Observations: Lung cancer screening (LCS) studies have found evidence of emphysema on computed tomography (CT) in patients without prior history of COPD. Detection of emphysema on CT allows PCPs to identify patients who may benefit from symptom screening, spirometry, and tobacco cessation efforts. In 2022, the Veterans Affairs Northeast Ohio Healthcare System internal medicine residents and faculty implemented a quality improvement project to increase early COPD diagnosis in primary care patients using CT for LCS.

Conclusions: We propose asking all patients who are eligible for LCS about their COPD symptoms and creating a clinical reminder for COPD screening in patients with tobacco use.

Background: A false-positive blood culture contamination rate of 3.0% is a widely recognized hospital benchmark. In November 2017, the Veterans Affairs Central Texas Healthcare System (VACTHCS), a 146-bed urban teaching hospital with about 30,000 annual emergency department (ED) visits, introduced the initial specimen diversion technique (ISDT) to reduce its contamination rate. ISDT uses blood draws to isolate and discard the initial portion of blood collected, known to be more prone to contamination from skin bacteria.

Methods: This retrospective comparative study of ISDT effectiveness was conducted at VACTHCS. Data were collected 36 months before and after ISDT implementation. Adults admitted to VACTHCS through the ED who required blood cultures for clinical suspicion of infection were included. Data were reviewed 36 months postimplementation to determine the effectiveness of the ISDT intervention.

Results: There was a marked decrease in contamination rates within the VACTHCS ED. Preimplementation, the mean contamination rate was 4.5% (95% CI, 3.90-4.90), which decreased to 2.6% (95% CI, 2.10-3.20) following ISDT implementation (P < .001).

Conclusions: Targeted interventions such as ISDT may reduce blood culture contamination rates in the ED. Incorporating ISDT at VACTHCS resulted in an overall blood culture contamination reduction and improved patient care.

Background: Limited staff, rising costs, and regulatory oversight, coupled with the need to achieve clinical endpoints and improve access to care, has made scaling health care operations challenging. This article explores the emerging paradigm of multiagent artificial intelligence (AI) systems in health care, which represent a significant leap beyond traditional large language models.

Observations: This analysis reviews the potential of multiagent AI systems to revolutionize patient care, streamline administrative processes, and support complex clinical decision-making. It describes a hypothetical sepsis management system comprising 7 specialized AI agents, with each agent handling specific aspects of patient care from data collection and diagnosis to treatment recommendations and resource management. Additional applications in chronic disease management and hospital patient flow optimization are also examined. The technical implementation of these systems is discussed, including the use of advanced large language models, interagent quality control measures, guardrail implementation, self-reflection mechanisms, integration with electronic health records, and the importance of explainable AI in ensuring decision transparency. Potential benefits include enhanced diagnostic accuracy and personalized treatment plans. Challenges remain related to data quality assurance, workflow integration, and ethical considerations. Future directions for AI include the integration of internet-enabled devices and the development of more sophisticated natural language interfaces.

Conclusions: This article underscores the transformative potential of multiagent AI systems in health care while emphasizing the importance of rigorous validation, ethical oversight, and a patient-centered approach in their development and implementation.

Background: Pharmacogenomic Testing for Veterans (PHASER) is a US Department of Veterans Affairs (VA) program that offers a 16-gene laboratory test panel to patients. Pharmacogenomic testing results may improve patient care by providing patient-specific information on how effective a medication may be or identifying increased risks for adverse drug effects. A VA Central Ohio Healthcare System Pharmacy department initiative sought to increase outpatient PHASER ordering by clinical pharmacist practitioners (CPPs).

Observations: CPPs were surveyed to address the current process and perceived barriers. Barriers identified by CPPs included a lack of clinician education materials, standardized screening process, comfort with PHASER ordering and education, support for the initiative, time constraints preventing patient education and ordering, higher priority clinical needs, forgetting to order, and increased workload and burnout. A gap analysis was used to create a new workflow with the goal of increasing PHASER orders by 50% after 3 months. The new workflow included prefilled templates, education, and visual reminders. PHASER orders increased from 87 preimplementation to 196 postimplementation, a 125% increase.

Conclusions: This quality improvement initiative resulted in an increase in PHASER orders and a clearly defined process. Perceived barriers were identified, and process changes attempted to address them in a sustainable way.

Background: Veterans can now access specialized care normally delivered at large tertiary US Department of Veterans Affairs (VA) medical centers (VAMCs). The costs are paid by their originating VAMC, but have not been comprehensively examined.

Methods: This study analyzes radiation oncology community care consultations, authorizations, standard episodes of care (SEOCs), and radiation oncology-specific charges at the Richard L. Roudebush VAMC (RLRVAMC) to provide a comprehensive view of the financial effects of sending patients to community care. It also demonstrates obstacles in categorization and suggests improvements to current VA practices.

Results: From October 1, 2021, to February 1, 2024, about $2.7 million was spent by RLRVAMC on community care radiation oncology services, with median SEOC charges of $5000. After accounting for inadvertently omitted radiation oncology costs and patients, total expenditures are closer to $2.9 million. The median cost of the consultation increased to $20,600 for patients who received community-based definitive radiation treatment.

Conclusions: Current methods for calculating community-based radiation oncology costs underestimate total expenditures, exclude some patients who receive radiotherapy services, and severely understate the median cost of care for those undergoing definitive treatment.

Background: Despite optimal statin therapy, many patients may be at increased cardiovascular risk if they do not meet their low-density lipoprotein (LDL) goals. Ezetimibe is used to lower LDL cholesterol and reduce cardiovascular events, yet it is underused in clinical practice, and its effectiveness and safety are not well studied in patients with and without chronic kidney disease (CKD).

Methods: This single-center, retrospective chart review sought to determine changes in LDL and non-high-density lipoprotein (non-HDL) levels and incidence of muscle-related adverse events (AEs) after addition of ezetimibe in patients without CKD. In addition, this study assessed changes in LDL and non-HDL levels and incidence of muscle-related AEs in patients with CKD. Data were obtained from the Computerized Patient Record System for patients prescribed ezetimibe by a patient aligned care team pharmacist at the Wilkes-Barre Veterans Affairs Medical Center.

Results: From September 1, 2021, through September 1, 2023, ezetimibe was initiated for 173 patients (36 patients with CKD and 137 without CKD). Patients without CKD had mean reductions in LDL and non-HDL levels of 23.5% and 21.7%, respectively. Patients with CKD had mean reductions in LDL and non-HDL levels of 27.0% and 24.8%, respectively. Muscle-related AEs occurred in 13.9% of patients in both groups.

Conclusions: A more pronounced reduction in mean LDL and non-HDL levels was seen with ezetimibe therapy than reported in the literature. Patients with CKD had greater reductions of LDL and non-HDL levels compared with patients without CKD, potentially due to increased accumulation. Muscle-related AEs did not differ between the groups, indicating that although ezetimibe accumulates more in patients with CKD, it was not correlated with increased risk of muscle-related AEs.

Background: Colorectal cancer (CRC) is the second-leading cause of cancer-related deaths in the United States. Rural living poses special challenges to CRC screening and management, but it is unclear whether rural/urban disparities persist within the Veterans Health Administration (VHA).

Methods: This study used VHA data to examine characteristics and mortality among veterans with newly diagnosed CRC. Urban areas were defined using Rural Urban Commuting Area categories 1.0 and 1.1; all other areas were classified as rural. Propensity score-matching analysis was used to address differences in baseline characteristics and compare mortality between rural and urban veterans with CRC. An additional propensity score-matching analysis focused on CRC among veterans aged ≤ 45 years.

Results: Of 2,460,727 individuals, there were 19,422 urban and 10,797 rural veterans with CRC (fiscal years 2016-2021). In rural areas, 83.6% of patients with CRC were White, compared to 67.8% in urban areas. Veterans with CRC in rural areas were also older, more likely to be obese, but had a lower Charlson Comorbidity Index (all P < .05). In the propensity score-matched cohort, baseline demographics and comorbidities were similar between rural and urban CRC patients. Total mortality occurred in 3702 urban veterans (34.3%) and 3763 rural veterans (34.9%) (hazard ratio [HR], 1.01; 95% CI, 0.97-1.06, P = .53). More patients with CRC were aged ≤ 45 years in urban areas (n = 391, 2.0%) than in rural areas (n = 160, 1.5%; P = .001), and their mortality was similar in the propensity score-matched group (HR, 0.97; 95% CI, 0.57-1.63).

Conclusions: Veterans with CRC in rural or urban areas had similar survival outcomes. The study implies that an integrated health system may help alleviate disparities between rural and urban America.