Togus VA Medical Center

BackgroundTravel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts’ intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers.ObjectiveThe Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented.DesignRetrospective, observational, utilizing administrative data.SubjectsVA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT).Main MeasuresObserved distance: distance between Veteran’s home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran’s home and nearest VA facility offering in-person equivalent of telehealth service.Key ResultsIn-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices.ConclusionsVeterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

The current emergency standards for training, exercises, communication, coordination, and response utilized by the United States (US) healthcare system are inadequate to meet patient needs before, during, and after disasters. Through a focused review of the literature and supporting expert interviews, this study aims to identify major barriers to US healthcare system resiliency in an emergency management context. Findings include that organizations across the healthcare system remain fragmented, often acting as standalone entities instead of being part of a larger ecosystem, which weakens the overall healthcare response framework. Despite advances in collaborative technology, many healthcare organizations rely on technologies that cannot meet their needs during a major emergency or disaster. Additionally, this research indicates that training and education standards need updates to match current and future disaster healthcare needs. Finally, based on the findings, seven recommendations were made as a starting point to what must be an ongoing discussion. While the recommendations are based on data from the US, this research has both national and international implications.

Phenomenon The 2020–2021 residency application cycle was subject to major alterations following the COVID-19 global pandemic. This study determined the online presence of US-based residency training programs during this time period. Approach An official list of accredited US residency programs for 24 medical specialties was obtained through the Electronic Residency Application Service Programs’ online presence and was evaluated for website ownership in addition to Twitter, Instagram, and Facebook account ownership. Date of social media account foundation and virtual opportunities offered were recorded. Doximity Residency Navigator for 2020–2021 was used to determine program rank, and programs were stratified by location using Association of American Medical Colleges regions. Program rank and geographic location were used to determine potential trends in online presence. This study was performed during the residency application cycle from September 2, 2020, to November 29, 2020, during which applications were submitted and the interview cycle began. Findings Fifty-seven percent of the 4,562 programs had a presence on social media. One-third of all accounts were created after March 1, 2020, and most (58%) were residency program–associated. A total of 1,315 programs offered virtual open houses through Twitter (829), Instagram (792), and Facebook (295). First-quartile programs had significantly more social media accounts per program on average (1.8) than those in subsequent quartiles, and Western region programs had significantly more accounts per program on average (1.3) than the Central (1.0), Northeastern (1.0), and Southern (1.1) regions. Insights US residency programs created social media accounts and online opportunities for applicants following March 1, 2020. Online interactions may serve as substitutes at a time when in-person interaction is not possible. Future studies may examine the influence and impact of virtual interactions.

Background: Central-line–associated bloodstream infections (CLABSIs) are a complication of indwelling central venous catheters, which increase morbidity, mortality, and cost to patients. Objective: Due to increased rates in a spinal cord injury unit (SCIU), a performance improvement project was started to reduce CLABSI in the patient population. Methods: To reduce the incidence of CLABSI, a prevention bundle was adopted, and a peer-surveillance tool was developed to monitor compliance with the bundle. Staff were trained to monitor their peers and submit weekly surveillance. Audits were conducted by the clinical nurse leader with accuracy feedback. Bundle peer-surveillance was implemented in February of 2018 with data being fed back to leadership, peer monitors, and stakeholders. Gaps in compliance were addressed with peer-to-peer education, changes in documentation requirements, and meetings to improve communication and reduce line days. In addition, the use of an antiseptic-impregnated disc for vascular accesses was implemented for dressing changes. Further quality improvement cycles during the first 2 quarters of fiscal year 2019 included service-wide education reinforcement, identification in variance of practice, and reporting to staff and stakeholders. Results: CLABSI bundle compliance increased from 67% to 98% between February and October 2018. The weekly audit reporting accuracy improved from 33% to 100% during the same period. Bundle compliance was sustained through the fourth quarter of 2019 at 98%, and audit accuracy was 99%. The initial CLABSI rates the quarter prior to the intervention were 6.10 infections per 1,000 line days for 1 of the 3 SCIUs and 2.68 infections per 1,000 line days for the service overall. After the action plan was initiated, no CLABSIs occurred for the next 3 quarters in all SCIUs despite unchanged use of central lines (5,726 line days in 2018). The improvement was sustained, and the line days decreased slightly for 2019, with a fiscal year rate of 0.61 per 1,000 line days (ie, 3 CLABSIs in 4,927 central-line days). Conclusions: The incidence of CLABSI in the SCIU was reduced by an intensive surveillance intervention to perform accurate peer monitoring of bundle compliance with weekly feedback, communication, and education strategies, improvement of the documentation, and the use of antiseptic-impregnated discs for dressings. Despite the complexity of the patient population requiring long-term central lines, the CLABSI rate was greatly impacted by evidence-based interventions coupled with reinforcement of adherence to the bundle.Funding: NoneDisclosures: None

Hypertension is the primary cause of cardiovascular mortality. Despite multiple existing treatments, only half of those with the disease achieve adequate control. Therefore, understanding the mechanisms causing hypertension is essential for the development of novel therapies. Many studies demonstrate that immune cell infiltration of the vessel wall, kidney and central nervous system, as well as their counterparts of oxidative stress, the renal renin-angiotensin system (RAS) and sympathetic tone play a critical role in the development of hypertension. Genetically modified mice lacking components of innate and/or adaptive immunity confirm the importance of chronic inflammation in hypertension and its complications. Depletion of immune cells improves endothelial function, decreases oxidative stress, reduces vascular tone and prevents renal interstitial infiltrates, sodium retention and kidney damage. Moreover, the ablation of microglia or central nervous system perivascular macrophages reduces RAS-induced inflammation and prevents sympathetic nervous system activation and hypertension. Therefore, understanding immune cell functioning and their interactions with tissues that regulate hypertensive responses may be the future of novel antihypertensive therapies.

Pheochromocytoma is a rare neuroendocrine tumor that affects people in the 4th and 5th decades of life. It can be benign or malignant, and present as isolated tumors or along with other neuroendocrine syndromes. We present a case of an elderly man who underwent laparoscopic adrenalectomy for pheochromocytoma when he was 58 years only to have a recurrence of metastatic malignant pheochromocytoma in his seventies. We also conducted a literature review to understand the epidemiology and presentation of the tumor and to emphasize that there should be a low threshold of suspicion for timely diagnosis and management of recurrent pheochromocytoma.

Background Referral rates and outcomes of cardiac rehabilitation have not been evaluated in patients with transcatheter aortic valve replacement or compared with surgical aortic valve replacement. Method A retrospective cohort study was conducted in 488 patients who underwent transcatheter aortic valve replacement ( n = 199) and surgical aortic valve replacement ( n = 289) from a university-based statewide transcatheter aortic valve replacement/surgical aortic valve replacement program during 2015-2017. Cardiac rehabilitation consisted of supervised exercise, diet education, and stress and depression management. We compared changes from baseline in exercise duration and intensity during cardiac rehabilitation sessions, quality-of-life (36-Item Short-Form Health Survey), and psychosocial measures (anxiety, depression, mood, social support, and diet) between transcatheter aortic valve replacement and surgical aortic valve replacement patients using t-test and chi-square analyses. Results Of 488 patients, cardiac rehabilitation referral rates were similar at 41% (transcatheter aortic valve replacement 81/199 versus surgical aortic valve replacement 117/289), but enrollment rates were lower in transcatheter aortic valve replacement (27/199, 14%) versus surgical aortic valve replacement (102/289, 35%, p < 0.01). Among eligible patients, cardiac rehabilitation completion rates were lower in transcatheter aortic valve replacement (12%) than surgical aortic valve replacement (32%). Exercise intensity during cardiac rehabilitation improved in both groups in a similar fashion (transcatheter aortic valve replacement 1.03 ± 1.09 versus surgical aortic valve replacement 1.34 ± 1.15 metabolic equivalents), but increase in exercise duration was higher in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients (14.52 ± 6.42 versus 10.67 ± 8.38 min, p = 0.02). Improvement in physical composite score was higher in surgical aortic valve replacement versus transcatheter aortic valve replacement (8.72 ± 7.87 versus 2.36 ± 7.6, p = 0.02) while improvement in mental composite score was higher in transcatheter aortic valve replacement (8.19 ± 8.50) versus surgical aortic valve replacement (1.18 ± 7.23, p = 0.02). There was no significant difference between the two groups in improvement in psychosocial measures. Conclusion Cardiac rehabilitation enrollment was low in transcatheter aortic valve replacement patients versus surgical aortic valve replacement patients despite similar referral rates. Improvement in functional and quality-of-life performance was achieved in both transcatheter aortic valve replacement and surgical aortic valve replacement. Future studies should address obstacles for enrollment of transcatheter aortic valve replacement patients.