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

Background: The US Department of Veterans Affairs (VA) is committed to embodying principles of high reliability organizations and Lean management culture. The practice of making problems readily known to team members and leadership is called visual management, an important tool in the journey to becoming a high reliability organization. Visual management boards (VMBs), or huddle boards, can foster transparency, teamwork, and employee empowerment.

Observations: A variety of health care teams at the Lieutenant Colonel Charles S. Kettles VA Medical Center within the VA Ann Arbor Healthcare System (VAAAHS) created and instituted VMBs. This article highlights the implementation in a large, diverse outpatient cardiology clinic. The incorporation of a VMB into the daily huddle of the outpatient cardiology clinic team led to increased problem identification among staff and leadership and fostered teamwork as issues were addressed. Feedback from teams across the VAAAHS noted how the boards were helpful in prioritizing areas for improvement, fostering teamwork, and increasing staff engagement, empowerment, and satisfaction.

Conclusions: A VMB is a simple, inexpensive, yet potentially powerful tool to bring together diverse health care teams to identify problems in the workplace, engage staff in developing solutions, and enhance communication with leadership. Implementation of VMBs at the VAAAHS may serve as a model for other VA health care systems for the incorporation of visual management into daily workplace culture.

Background: Having a sufficient number of gastroenterologists is important for protecting the digestive health of veterans. However, gastroenterology is among the most difficult medical specialties for recruitment at the US Department of Veterans Affairs (VA).

Methods: We surveyed VA gastroenterology section chiefs to learn about current barriers to recruitment and retention and to identify opportunities for improvement.

Results: Of 131 VA gastroenterology section chiefs at VA medical centers who received the survey, 55 responded (42%). Thirty-six respondents (65%) reported current vacancies at their facilities (range, 1-4). Low salary and human resources challenges were the most frequently reported barriers to recruitment. Low salary and administrative burden, including lack of sufficient support staff, were the most frequently reported barriers to retention.

Conclusions: While salary is the most frequently reported barrier to recruitment and retention, human resources challenges represent the second-most frequently reported barrier to recruitment. Administrative burden linked to suboptimal staffing support is the second most frequently reported barrier to retention. Efforts to raise salaries (higher than the current $400,000 ceiling), streamline human resources processes, and reduce administrative burden are needed to ensure a thriving VA gastroenterology workforce.

Background: Within the US Department of Veterans Affairs (VA), eligible veterans can receive covered health care through the community care network. Many prescriptions for specialty medications made by community care prescribers are filled by outpatient VA pharmacies. Trained hematology/oncology clinical pharmacy practitioners (CPPs) review specialty medication prescriptions from community-based prescribers. This study's primary objective was to evaluate clinical interventions initiated by hematology/oncology CPPs at the Veterans Affairs North Texas Health Care System (VANTHCS) during their review of hematology/oncology specialty prescriptions from community care prescribers.

Methods: A retrospective chart review of VANTHCS patients enrolled in the community care program with a specialty hematology/oncology prescription received and reviewed by a VA clinical hematology/oncology CPP was conducted for records from January 1, 2015, to June 30, 2023. The primary outcome was the number and types of clinical interventions. Secondary outcomes include the number of interventions accepted and/or denied by the prescriber and the financial implications of these interventions.

Results: Two hundred twenty-one specialty hematology/oncology prescriptions met the study inclusion criteria. VANTHCS hematology/oncology CPPs completed clinical interventions for 82 prescriptions (37%). Among those prescriptions, CPPs documented 97 clinical interventions. The most commonly documented interventions included managing/preventing a drug interaction (26%) and dose adjustment requests (25%).

Conclusions: Hematology/oncology CPPs at VANTHCS are essential in reviewing anticancer medication prescriptions from community-based practitioners ; CPPs completed clinical interventions for more than one-third of the prescriptions and prescribers approved most of these interventions.

Background: Paclitaxel is an antineoplastic agent used to treat breast, lung, endometrial, cervical, pancreatic, sarcoma, and thymoma cancer. However, drugs that induce, inhibit, or are substrates of cytochrome P450 (CYP) isoenzymes 2C8 or 3A4 may alter the metabolism of paclitaxel, potentially impacting its effectiveness. The purposes of this study are to provide an overview of paclitaxel use, identify potential drugs that interact with paclitaxel, and describe their clinical manifestations.

Methods: A retrospective analysis was performed on patients receiving paclitaxel to evaluate types and stages of cancer, treatment regimens, and adverse events of paclitaxel alone or paclitaxel in combination with other antineoplastic drugs, using data retrieved in March 2022 from the US Department of Defense Cancer Registry. Additionally, the study compared the health issues and prescriptions of patients who completed treatment with those who discontinued treatment. It evaluated interactions of paclitaxel with noncancer drugs, particularly antidepressants metabolizing and inhibiting CYP3A4, using data from the Comprehensive Ambulatory/Professional Encounter Record and the Pharmacy Data Transaction Service database. Data were retrieved in October 2022.

Results: Of 702 patients prescribed paclitaxel, 338 completed treatment. Paclitaxel discontinuation alone vs concomitantly (P < .001) and 1 drug vs combination (P < .001) both were statistically significant. Patients who took paclitaxel concomitantly with a greater number of prescription drugs had a higher rate of treatment discontinuation than those who received fewer medications. Patients in the completed group received 9 to 56 prescription drugs, and those in the discontinued group were prescribed 6 to 70. Those who discontinued treatment had more diagnosed medical issues than those who completed treatment.

Conclusions: The study provides a comprehensive overview of paclitaxel usage from 1996 through 2022 and highlights potential drug interactions that may affect treatment outcomes. While the impact of prescription drugs on paclitaxel discontinuation is uncertain, paclitaxel and antidepressants do not have significant drug-drug interactions.

Background: Glomerulopathy involves damage to the glomerular filtration barrier for several reasons, resulting in idiopathic nephrotic syndrome (NS). Treatment options are limited and often include steroids with varying levels of response.

Case presentation: A 7-year-old male with a history of NS at age 2 years that developed following a respiratory tract infection was found to have a heterozygous variant of uncertain significance in COL4A4 and TRPC6 genes. Biopsy findings included podocytopathy and changes in the basement membrane. Upon initial response to steroids, the patient was treated with a brief course of anakinra followed by adalimumab for > 2 years as steroid-sparing biological response modifiers. After a gradual taper, the patient remains in remission and has not received treatment in the last 12 months.

Conclusions: This case shows the complex nature of biologically predetermined cascading events in the emergence of glomerular disease with environmental triggers and genetic factors. Downregulation of somatic tissue-driven proinflammatory milieu originating from the constituents of the glomerular microenvironment can help in recovery from emerging podocytopathy. Blocking tumor necrosis factor-α early in the disease course, even temporarily, may allow time for the de novo regenerative process to prevail. Additional research is warranted to test this hypothesis and minimize steroid use.

Background: The demographic characteristics of veterans has changed significantly in recent years and continues to become more diverse. To enhance the quality of health care for the current community of enrolled veterans, it is critical that the physicians and health care leaders of the Veterans Health Administration (VHA) understand the changing demographics and health care needs of the veteran population.

Observations: Studies have shown that increased inclusion, diversity, and equity among clinicians are associated with improved clinical outcomes. Diversity encompasses more than race and gender. Although the VHA workforce is relatively diverse, the same cannot be said about its leadership. The I*DEA (inclusion, diversity, equity, and access) Council is a new program that aims to eliminate gaps in VHA care and benefits to ensure that historically underserved veteran communities receive fair treatment.

Conclusions: Optimizing I*DEA strategies-inclusion of diverse perspectives and ideas, equity of opportunities and accessibility within the VHA workforce-may help to enhance the quality of health care for veterans.

Background: Compartment syndrome of the upper extremity is a surgical emergency that most often presents after an identifiable event, such as a crush injury, a closed fracture, a snake bite, reperfusion after embolectomy, an electrical injury, or a circumferential burn.

Case presentation: We report an unusual case in which an older woman was diagnosed with acquired factor VIII deficiency after presenting with acute nontraumatic compartment syndrome in her right upper extremity. Emergency medicine, plastic surgery, internal medicine, hematology, and hand therapy specialists worked together to identify the pathology and successfully treat the patient.

Conclusions: An isolated elevated partial thromboplastin time level in a patient who is bleeding should raise suspicions for factor VIII deficiency and immediately trigger further evaluation. Once this diagnosis is suspected, multidisciplinary treatment is indicated for immediate and long-term successful outcomes.

Background: At-risk rural veterans have low rates of lung cancer screening (LCS). This proof-of-principle quality improvement project aimed to determine whether a telehealth intervention would increase referrals for at-risk veterans living in the rural upper Midwest and attending a smoking cessation program to LCS with low-dose computed tomography (LDCT) of the chest.

Methods: Sixty-eight of 74 LCS-eligible rural veterans who self-enrolled in a smoking cessation program were contacted by telephone. Those who agreed to enroll in LCS were referred to LDCT and followed for 4 months. At the conclusion of the intervention, the number of referrals and screenings performed were tabulated. LDCT reports were reviewed and scored according to Lung CT Screening Reporting and Data System (Lung-RADS) version 1.1.

Results: Only 3 of 74 LCS-eligible veterans (4%) underwent LDCT before initiation of this telehealth intervention. By the conclusion of this 4-month project, 19 of 74 veterans (26%) underwent LDCT. Forty-one veterans were successfully contacted and 29 agreed to participate in LCS. Of those who agreed to participate, 19 underwent LDCT within 4 months. Of the veterans who received LDCT, 10 were diagnosed with Lung-RADS 1, 7 with Lung-RADS 2, 1 with Lung-RADS 3, and 1 with Lung-RADS 4B. Annual follow-up LDCT or referral for further evaluation were pursued in each case.

Conclusions: Collectively, these data suggest that telehealth intervention could increase referrals of at-risk rural veterans to a centralized LCS program at a regional US Department of Veterans Affairs medical facility.

Background: Predicting life expectancy and providing an end-of-life diagnosis in hospice is very challenging for most clinicians given their generally poor training for this role and limited medical education. End-of-life diagnosis alone is often used to certify hospice appropriateness. It is essential, however, to document good supporting evidence of decline and comorbidities. Functional status can be a helpful criterion prior to hospice admission and during required 90-day certifications.

Case presentation: An 80-year-old male who was diagnosed with Stage IV glioblastoma multiforme was transferred from an acute care hospital to a community living center hospice service for end-of-life care. After 6 months of care, the veteran was able to graduate from hospice and transfer to an adult living facility with minimal care needs.

Conclusions: Recognizing the importance of documenting and using functional scales in individuals receiving hospice care is extremely helpful in prognostication.