Opportunities for improving opioid disposal practices in the Veterans Health Administration

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The potentially vast supply of unused opioids in Americans’ homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. Methods We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. Results While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. Conclusion A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.

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Incidence of Clostridioides difficile infections among young and middle-aged adults: Veterans Health Administration

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.160 ◽

2019 ◽

Vol 40 (9) ◽

pp. 997-1005 ◽

Cited By ~ 1

Author(s):

Ellyn M. Russo ◽

Jennifer Kuntz ◽

Holly Yu ◽

Jeremy Smith ◽

Ronald George Hauser ◽

...

Keyword(s):

Veterans Health Administration ◽

Health Concern ◽

Charlson Comorbidity Index Score ◽

Veterans Health ◽

Health Administration ◽

Middle Aged ◽

Clostridioides Difficile ◽

Using Data ◽

Middle Aged Adult

AbstractObjective:Clostridioides difficile infection (CDI) remains a significant public health concern, resulting in excess morbidity, mortality, and costs. Additional insight into the burden of CDI in adults aged <65 years is needed.Design/Setting:A 6-year retrospective cohort study was conducted using data extracted from United States Veterans Health Administration electronic medical records.Patients/Methods:Patients aged 18–64 years on January 1, 2011, were followed until incident CDI, death, loss-to-follow-up, or December 31, 2016. CDI was identified by a diagnosis code accompanied by metronidazole, vancomycin, or fidaxomicin therapy, or positive laboratory test. The clinical setting of CDI onset was defined according to 2017 SHEA-IDSA guidelines.Results:Of 1,073,900 patients, 10,534 had a CDI during follow-up. The overall incidence rate was 177 CDIs per 100,000 person years, rising steadily from 164 per 100,000 person years in 2011 to 189 per 100,000 person years in 2016. Those with a CDI were slightly older (55 vs 51 years) and sicker, with a higher baseline Charlson comorbidity index score (1.4 vs 0.5) than those without an infection. Nearly half (48%) of all incident CDIs were community associated, and this proportion rose from 41% in 2011 to 56% in 2016.Conclusions:The findings from this large retrospective study indicate that CDI incidence, driven primarily by increasing community-associated infection, is rising among young and middle-aged adult Veterans with high service-related disability. The increasing burden of community associated CDI in this vulnerable population warrants attention. Future studies quantifying the economic and societal burden of CDI will inform decisions surrounding prevention strategies.

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Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.203 ◽

2021 ◽

pp. 1-6

Author(s):

Daniel J. Livorsi ◽

Kenda R. Stewart Steffensmeier ◽

Eli N. Perencevich ◽

Matthew Bidwell Goetz ◽

Heather Schacht Reisinger

Keyword(s):

Infectious Disease ◽

Antibiotic Stewardship ◽

Staff Turnover ◽

Veterans Health ◽

Health Administration ◽

Institutional Barriers ◽

Potential Barriers ◽

Primary Responsibility ◽

Semistructured Interviews ◽

Infectious Disease Specialists

Abstract Background: Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. Objective: In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans’ Health Administration (VHA). Methods: Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. Setting: The study was conducted across 7 VHA hospitals. Participants: In total, 42 hospital personnel were enrolled in the study. Results: The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. Conclusion: In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

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Firearm Injury Encounters in the Veterans Health Administration (VHA), 2010-2015

Online Journal of Public Health Informatics ◽

10.5210/ojphi.v9i1.7716 ◽

2017 ◽

Vol 9 (1) ◽

Author(s):

Cynthia Lucero-Obusan ◽

Aaron Wendelboe ◽

Patricia Schirmer ◽

Gina Oda ◽

Mark Holodniy

Keyword(s):

Public Health ◽

Admission Rate ◽

Time Frame ◽

Health Concern ◽

Inpatient Setting ◽

Veterans Health ◽

Health Administration ◽

Firearm Injury ◽

Number Of Patients ◽

Vietnam Era

IntroductionFirearm violence is an issue of public health concern leading tomore than 30,000 deaths and 80,000 nonfatal injuries in the UnitedStates annually.1To date, firearm-related studies among Veteranshave focused primarily on suicide and attempted suicide.2-5Herein,we examine firearm violence among VHA enrollees for all manners/intents, including assault, unintentional, self-inflicted, undeterminedand other firearm-related injury encounters in both the inpatient andoutpatient settings.MethodsInpatient and Outpatient encounters with one or more ICD-9-CM firearm external-cause-of-injury codes (E-codes) from1/1/2010-9/30/2015 were extracted from the VHA’s Praedico™Public Health Surveillance System, including demographics, era ofservice/eligibility, encounter type, and deaths. Firearm E-codes wereclassified for manner/intent based on the CDC’s Web-based InjuryStatistics Query and Reporting System (WISQARS™) matrix.6Outpatient/emergency department (ED) data were exclusively fromVHA facilities (a single pediatric patient seen as a humanitarianemergency was excluded from the dataset). Inpatient data includedVHA facilities and some records received from non-VHA facilities.VHA rate of hospitalization for firearm-related admissions wascalculated using the total VHA acute-care admissions for the sametime period as the denominator.ResultsDuring the time frame examined, 5,205 unique individuals wereseen with a firearm E-code. Of these, 4,221 were seen in the outpatient/ED setting only, 597 in the inpatient setting only, and the remaining387 had encounters in both the outpatient/ED and inpatient settings.VHA firearm admission rate was 1.63 per 10,000 VHA admissions,compared to a national rate of 1.96 per 10,000 in 2010.7Table 1 showsthe breakdown of encounters by manner/intent. Unintentional was themost common firearm injury manner/intent. Overall, the median age atinitial encounter was 54 (range 19-100 years), and 96% were male. Thehighest percentage served in the Persian Gulf War Era (2,136, 41%),followed by Vietnam Era (1,816, 35%) and Post-Vietnam Era (716,14%). The greatest number of patients with a firearm-coded encounterresided in Texas (453), California (349), Florida (326), Arizona (214)and Ohio (212).ConclusionsUnintentional injuries were the most common form of firearminjury among VHA enrollees, representing over half of alloutpatient/ED firearm encounters and more than twice the numberof firearm hospitalizations compared with any other manner/intent.Limitations include that not all U.S. Veterans are VHA enrollees;miscoding and misclassification of firearm-related injuries may haveoccurred; and data from non-VHA outpatient/ED encounters andsome non-VHA hospitalizations are not available to our surveillancesystem for analysis. Additional study is needed to further understandthe epidemiology of firearm-related injuries among Veterans andinform VHA leadership and providers

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“Asking Is Never Bad, I Would Venture on That”: Patients’ Perspectives on Routine Pain Screening in VA Primary Care

Pain Medicine ◽

10.1093/pm/pnaa016 ◽

2020 ◽

Vol 21 (10) ◽

pp. 2163-2171

Author(s):

Karleen F Giannitrapani ◽

Marie C Haverfield ◽

Natalie K Lo ◽

Matthew D McCaa ◽

Christine Timko ◽

...

Keyword(s):

Primary Care ◽

Health Care Systems ◽

Routine Care ◽

Veterans Health ◽

Health Administration ◽

Psychological Pain ◽

Patient Recall ◽

Semistructured Interviews ◽

Care Systems ◽

Screening Assessment

Abstract Objective Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients’ perspectives and preferences about the experience of being screened for pain in primary care. Design Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management. Subjects We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems. Methods We evaluated transcripts using constant comparison and identified emergent themes. Results Theme 1: Pain screening can “determine the tone of the examination”; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain. Conclusion Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.

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Analyzing the Clinical Outcomes of a Rapid Mass Conversion From Rosuvastatin to Atorvastatin in a VA Medical Center Outpatient Setting

Journal of Pharmacy Technology ◽

10.1177/8755122517719545 ◽

2017 ◽

Vol 33 (5) ◽

pp. 189-194 ◽

Cited By ~ 1

Author(s):

Chad Naville-Cook ◽

Leroy Rhea ◽

Mark Triboletti ◽

Christina White

Keyword(s):

Alkaline Phosphatase ◽

Clinical Outcomes ◽

Medical Center ◽

Density Lipoprotein ◽

Extended Period ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Secondary Endpoints ◽

Rapid Mass

Background: Medication conversions occur frequently within the Veterans Health Administration. This manual process involves several pharmacists over an extended period of time. Macros can automate the process of converting a list of patients from one medication to a therapeutic alternative. Objectives: To develop a macro that would convert active rosuvastatin prescriptions to atorvastatin and to create an electronic dashboard to evaluate clinical outcomes. Methods: A conversion protocol was approved by the Pharmacy & Therapeutics Committee. A macro was developed using Microsoft Visual Basic. Outpatients with active prescriptions for rosuvastatin were reviewed and excluded if they had a documented allergy to atorvastatin or a significant drug-drug interaction. An electronic dashboard was created to compare safety and efficacy endpoints pre- and postconversion. Primary endpoints included low-density lipoprotein (LDL), creatine phosphokinase (CPK), aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase. Secondary endpoints evaluated cardiovascular events, including the incidences of myocardial infarction, stroke, and stent placement. Results: The macro was used to convert 1520 patients from rosuvastatin to atorvastatin over a period of 20 hours saving $5760 in pharmacist labor. There were no significant changes in LDL, AST, ALT, or secondary endpoints ( P > .05). There was a significant increase in alkaline phosphatase ( P = .0035). Conclusions: A rapid mass medication conversion from rosuvastatin to atorvastatin saved time and money and resulted in no clinically significant changes in safety or efficacy endpoints. Macros and clinical dashboards can be applied to any Veterans Health Administration facility.

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An Intervention With Meaning

Crisis ◽

10.1027/0227-5910/a000433 ◽

2017 ◽

Vol 38 (6) ◽

pp. 376-383 ◽

Cited By ~ 2

Author(s):

Brooke A. Levandowski ◽

Constance M. Cass ◽

Stephanie N. Miller ◽

Janet E. Kemp ◽

Kenneth R. Conner

Keyword(s):

High Risk ◽

Qualitative Methodology ◽

Veterans Health Administration ◽

Veterans Health ◽

Safety Planning ◽

Health Administration ◽

Suicide Method ◽

Treatment Providers ◽

Interactive Nature ◽

Behavioral Health Treatment

Abstract. Background: The Veterans Health Administration (VHA) health-care system utilizes a multilevel suicide prevention intervention that features the use of standardized safety plans with veterans considered to be at high risk for suicide. Aims: Little is known about clinician perceptions on the value of safety planning with veterans at high risk for suicide. Method: Audio-recorded interviews with 29 VHA behavioral health treatment providers in a southeastern city were transcribed and analyzed using qualitative methodology. Results: Clinical providers consider safety planning feasible, acceptable, and valuable to veterans at high risk for suicide owing to the collaborative and interactive nature of the intervention. Providers identified the types of veterans who easily engaged in safety planning and those who may experience more difficulty with the process. Conclusion: Additional research with VHA providers in other locations and with veteran consumers is needed.

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