Use of a Deprescribing Tool in an Interdisciplinary Primary-Care Patient-Aligned Care Team

Objective: To pilot the VIONE approach in a single Primary Care Patient Aligned Care Team (PACT). The authors aim for the Clinical Pharmacy Specialist (CPS) to perform 20 comprehensive medication reviews (CMRs) and the pilot PACT physician (PCP) to complete 200 VIONE discontinuations. Cost avoidance and CPS recommendations will also be analyzed. Polypharmacy is associated with increased risk of adverse drug events, falls, hospitalizations, and death. VIONE is a deprescribing tool that assists providers in identifying inappropriate medications. Design: Quality Improvement Setting: Single VA Health Care System (VAHCS) Participants: High-risk veterans in pilot PACT Interventions: The CPS educated the PCP regarding VIONE methodology and assisted with CMRs. When deprescribing was warranted, VIONE discontinuation reasons were selected in the Computerized Patient Record System (CPRS). Data were electronically stored in a national dashboard. Results: The authors identified 231 veterans at risk for polypharmacy-related adverse events. The PCP and CPS were able to reach 99 veterans and make 136 medication discontinuations between September 1, 2019, and March 1, 2020. The CPS performed 20 CMRs, resulting in 90 deprescribing recommendations. Thirty-eight CPS recommendations were accepted and contributed $18,835.95 to the sum annualized cost avoidance of $21,904.80. Conclusion: The VIONE methodology was successfully implemented in the pilot PACT. The utilization of the CPS was associated with an increased average number of medication discontinuations per veteran and contributed to cost avoidance.

Abstract 9774: Shockable Rhythms Are Common First Rhythms in Cardiac Arrests Involving Patient with Heart Failure with Preserved Ejection Fraction

Introduction: Sudden cardiac death (SCD) is responsible from 25% of the total mortality in patients with heart failure with preserved ejection fraction (HFpEF). Whether SCD in HFpEF is due to shockable or unshockable rhythms is unknown. Hypothesis: Cardiac arrests in HFpEF are due to ventricular tachycardia/ventricular fibrillation (VT/VF). Methods: We determined the initial rhythm in 286 consecutive in-hospital cardiac arrests at the Minneapolis VA Health Care system from 2011 through 2020. Clinical and survival information were obtained from electronic health records. According to their heart failure history, we categorized the patients as HFpEF, heart failure with reduced ejection fraction (HFrEF) or no heart failure (NoHF). Results: Of the 286 patients (mean age 70.2±9.0 years old and 97.5% male), 51 (17.8%) had HFpEF, 77 (26.9%) had HFrEF and 158 (55.2%) had NoHF. The initial rhythm was VT/VF in 47.1%, 39.0% and 22.2% of patients with HFpEF, HFrEF and NoHF respectively (p<0.001) (Figure). Return of spontaneous circulation (ROSC) after VT/VF arrest was similar amongst the three groups (66.7%, 73.3% and 74.3%, respectively; p=0.8) but the 30-day survival trended higher in HFpEF (54.2%) and NoHF (48.6%) when compared with HFrEF (26.7%) (p=0.08)(Figure). Among patients with HFpEF, 30-day survival was lower after cardiac arrests due to PEA/Asystole when compared to those due to VT/VF (18.5% vs. 54.2%, respectively, p=0.03). Conclusion: VT/VF was the initial rhythm in 47% of patients with HFpEF who had in-hospital cardiac arrest. The proportion of VT/VF and ROSC after in-hospital cardiac arrest was similar in HFpEF and HFrEF. These data provide one more piece of evidence that SCD could be a therapeutic target in HFpEF.

Digital Health Literacy and Preparedness: Comparison of Veterans Health Affairs Users and Other Veterans Nationally (Preprint)

BACKGROUND As health care systems shift to greater use of telemedicine and digital tools, an individual’s digital health literacy has become an important skill set. The Veterans Health Administration (VA) has invested resources in providing digital health care; however, to date, no study has compared the digital health literacy and preparedness of Veterans receiving care in the VA to Veterans receiving care outside the VA. OBJECTIVE Describe digital health literacy and preparedness among Veterans who receive care within and outside the VA health care system and examine whether receiving care in the VA is associated with digital preparedness (having >2 digital health literacy skills) after accounting for demographic and social risk factors. METHODS We used cross-sectional data from the 2016-18 National Health Interview Survey to identify Veterans (age>18) who obtain health care either within or outside the VA health care system. We used multivariable logistic regression models to examine the association of sociodemographic (age, sex, race, ethnicity), social risk factors (economic instability, disadvantaged neighborhood, low educational attainment, and social isolation), and health care delivery location (VA and non-VA) with digital preparedness. RESULTS Those who received health care within the VA health care system (n=3,188) were younger (age 18-49: 33.3% [30.7-36.0] vs. 24.2% [21.9-26.5], p<0.01), were more often female (34.7% [32.0-37.3] vs. 6.6% [5.5-7.6], p<0.01) and identified as Black (13.1% [11.2-15.0] vs. 10.2% [8.7-11.8], p<0.01), and reported greater economic instability (8.3% [6.9-9.8] vs. 5.5% [4.6-6.5], p<0.01) and social isolation (42.6% [40.3-44.9] vs. 35.4% [33.4-37.5], p<0.01) compared to Veterans who received care outside the VA (n=3,393). Veterans who obtained care within the VA reported higher digital health literacy than those who obtained care outside the VA, endorsing greater rates of looking up health information on the internet (51.8% [49.2-54.4] vs. 45.0% [42.6-47.3], p<0.01), filling a prescription using the internet (16.2% [14.5-18.0] vs. 11.3% [9.6-13.0], p<0.01), scheduling a health care appointment on the internet (14.1% [12.4-15.8] vs. 11.6% [10.1-13.1], p=0.02), and communicating with a health care provider by email (18.0% [16.1-19.8] vs. 13.3% [11.6-14.9], p<0.01). In adjusted analysis, age >75 (aOR: 0.59, 95% CI 0.45-0.76), low educational attainment (aOR: 0.40, 95% CI 0.34-0.48) and social isolation (aOR: 0.78, 95% CI 0.66-0.92) were associated with a lower likelihood of being digitally prepared. Receiving health care from the VA was the only characteristic associated with higher odds (aOR: 1.36, 95% CI 1.12-1.65) of being digitally prepared. CONCLUSIONS Despite these demographic disadvantages to digital uptake, Veterans who receive care in the VA have higher digital health literacy and appear more digitally prepared than Veterans who do not receive care within the VA – suggesting a positive, system-level influence on this cohort.

Prostate Cancer: 2021 ASCO Annual Meeting Highlights for the Advanced Practitioner

Morgane C. Diven, PharmD, BCOP, of Phoenix VA Health Care System, evaluates research on an investigational radiolabeled small molecule, combination therapy in the treatment of de novo metastatic prostate cancer, and a CYP17-lyase inhibitor in metastatic hormone-sensitive prostate cancer. Coverage provided by The ASCO Post.

Age differences in the association of comorbid burden with adverse outcomes in SARS-CoV-2

Background Older age and comorbid burden are both associated with adverse outcomes in SARS-CoV-2, but it is not known whether the association between comorbid burden and adverse outcomes differs in older and younger adults. Objective To compare the relationship between comorbid burden and adverse outcomes in adults with SARS-CoV-2 of different ages (18–64, 65–79 and ≥ 80 years). Design, setting, and participants Observational longitudinal cohort study of 170,528 patients who tested positive for SARS-CoV-2 in the US Department of Veterans Affairs (VA) Health Care System between 2/28/20 and 12/31/2020 who were followed through 01/31/2021. Measurements Charlson Comorbidity Index (CCI); Incidence of hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and death within 30 days of a positive SARS-CoV-2 test. Results The cumulative 30-day incidence of death was 0.8% in cohort members < 65 years, 7.1% in those aged 65–79 years and 20.6% in those aged ≥80 years. The respective 30-day incidences of hospitalization were 8.2, 21.7 and 29.5%, of ICU admission were 2.7, 8.6, and 11% and of mechanical ventilation were 1, 3.9 and 3.2%. Median CCI (interquartile range) ranged from 0.0 (0.0, 2.0) in the youngest, to 4 (2.0, 7.0) in the oldest age group. The adjusted association of CCI with all outcomes was attenuated at older ages such that the threshold level of CCI above which the risk for each outcome exceeded the reference group (1st quartile) was lower in younger than in older cohort members (p < 0.001 for all age group interactions). Limitations The CCI is calculated based on diagnostic codes, which may not provide an accurate assessment of comorbid burden. Conclusions Age differences in the distribution and prognostic significance of overall comorbid burden could inform clinical management, vaccination prioritization and population health during the pandemic and argue for more work to understand the role of age and comorbidity in shaping the care of hospitalized patients with SARS-CoV-2.

Universal Masking to Control Healthcare-Associated Transmission of SARS-CoV-2

Objective: To assess extent of a healthcare-associated outbreak of SARS-CoV-2 and evaluate effectiveness of infection control measures, including universal masking Design: Outbreak investigation including 4 large-scale point-prevalence surveys Setting: Integrated VA Health Care System with 2 facilities and 330 beds Participants: Index patient and 250 exposed patients and staff Methods: We identified exposed patients and staff and classified them as probable and confirmed cases based on symptoms and testing. We performed a field investigation and assessment of patient and staff interactions to develop probable transmission routes. Infection prevention interventions implemented included droplet and contact precautions, employee quarantine, and universal masking with medical and cloth facemasks. Four point-prevalence surveys of patient and staff subsets were conducted using real-time reverse-transcriptase polymerase chain reaction for SARS-CoV-2. Results: Among 250 potentially exposed patients and staff, 14 confirmed cases of Covid-19 were identified. Patient roommates and staff with prolonged patient contact were most likely to be infected. The last potential date of transmission from staff to patient was day 22, the day universal masking was implemented. Subsequent point-prevalence surveys in 126 patients and 234 staff identified 0 patient cases and 5 staff cases of Covid-19, without evidence of healthcare-associated transmission. Conclusions: Universal masking with medical facemasks was effective in preventing further spread of SARS-CoV-2 in our facility in conjunction with other traditional infection prevention measures.

Women Veterans’ Experiences with Integrated, Biopsychosocial Pain Care: A Qualitative Study

Objectives Biopsychosocial, integrated pain care models are increasingly implemented in the Veterans Health Administration to improve chronic pain care and reduce opioid-related risks, but little is known about how well these models address women veterans’ needs. Design Qualitative, interview-based study. Setting San Francisco VA Health Care System Integrated Pain Team (IPT), an interdisciplinary team that provides short-term, personalized chronic pain care emphasizing functional goals and active self-management. Subjects Women with chronic pain who completed ≥3 IPT sessions. Methods Semistructured phone interviews focused on overall experience with IPT, perceived effectiveness of IPT care, pain care preferences, and suggested changes for improving gender-sensitive pain care. We used a rapid approach to qualitative thematic analysis to analyze interviews. Results Fourteen women veterans (mean age 51 years; range 33–67 years) completed interviews. Interviews revealed several factors impacting women veterans’ experiences: 1) an overall preference for receiving both primary and IPT care in gender-specific settings, 2) varying levels of confidence that IPT could adequately address gender-specific pain issues, 3) barriers to participating in pain groups, and 4) barriers to IPT self-management recommendations due to caregiving responsibilities. Conclusions Women veterans reported varied experiences with IPT. Recommendations to improve gender-sensitive pain care include increased provider training; increased knowledge of and sensitivity to women’s health concerns; and improved accommodations for prior trauma, family and work obligations, and geographic barriers. To better meet the needs of women veterans with chronic pain, integrated pain care models must be informed by an understanding of gender-specific needs, challenges, and preferences.