The Clinical Resource Hub Initiative: First-Year Implementation of the Veterans Health Administration Regional Telehealth Contingency Staffing Program.

Health care systems face challenges providing accessible health care across geographically disparate sites. The Veterans Health Administration (VHA) developed regional telemedicine service focusing initially on primary care and mental health services. The objective of this study is to describe the program and progress during the early implementation. In its first year, the Clinical Resource Hub program provided 244 515 encounters to 95 684 Veterans at 475 sites. All 18 regions met or exceeded minimum implementation requirements. The regionally based telehealth contingency staffing hub met early implementation goals. Further evaluation to review sustainability and impact on provider experience and patient outcomes is needed.

Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans.

BACKGROUND: Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs. OBJECTIVE: To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans. METHODS: A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre-post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans. RESULTS: A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre-post analysis with sustained effects in the postintervention period. CONCLUSIONS: Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

Implementation of a Urinary Tract Infection Treatment Protocol to Improve Prescribing Practices in the Long-Term Care Facility of a Veteran's Healthcare System.

Urinary tract infections (UTIs) are a commonly diagnosed problem in long-term care facilities (LTCFs), but antimicrobial treatment is often incorrectly prescribed. Although bacterial resistance to antimicrobials commonly used for UTIs, such as trimethoprim/sulfamethoxazole and fluoroquinolones, has been dramatically increasing, they are still commonly prescribed. The purpose of this project was to determine if implementation of a standard treatment protocol for UTIs, which emphasized correct UTI diagnosis and use of nitrofurantoin and cefpodoxime/ceftriaxone as empiric therapy per the institutional antibiogram, changed clinician prescribing practices. This quasi-experimental model utilized two years of pre-intervention and two years of post-intervention data. Three hundred patient encounters were included. Antibiotics prescribed in the pre-intervention period included: trimethoprim/sulfamethoxazole (32%), ciprofloxacin (14%), amoxicillin (13%), levofloxacin (9%), cefpodoxime (9%), ceftriaxone (8%), amoxicillin/clavulanate (5%), nitrofurantoin (4%), and other (6%). By contrast, antibiotics prescribed in the post-intervention period included: cefpodoxime (46%), nitrofurantoin (30%), ceftriaxone (10%), trimethoprim/sulfamethoxazole (8%), amoxicillin/clavulanate (1%), and other (5%). These differences in prescribed drug between the pre-intervention and post-intervention encounters were statistically significant (p < 0.001). Overall, appropriate empiric treatment was prescribed in only 48/217 encounters (22%) during the pre-intervention period, but this increased to 73/83 encounters (88%) in the post-intervention period (p < 0.001). The results indicate that the treatment protocol was successful in changing prescribing practices and decreasing the use of inappropriate antimicrobials at the LTCF.

Enhancing Clinical Pharmacy Specialist Involvement in Transitions of Care Focusing on Ambulatory Care Sensitive Conditions within a Veterans Affairs Healthcare System.

The purpose of this quality improvement project was to evaluate the impact of clinical pharmacy specialist (CPS) involvement in the post-discharge period on 30-day readmission rates within a Veterans Affairs Healthcare System. Patients eligible for inclusion were discharged from a Veterans Affairs (VA) acute care facility with a principle or secondary diagnosis of heart failure (HF), chronic obstructive pulmonary disease (COPD), or both HF and COPD from 15 October 2018 through 14 January 2019. CPSs functioning as a mid-level provider with a scope of practice conducted telephone and in-clinic medication management appointments within 7 and 21 days post-discharge for qualifying patients discharged with a principle or secondary diagnosis of HF or COPD. CPS appointments focused on medication reconciliation, ensuring continuity of care, disease state counseling, and medication management. By enhancing the role of the CPS in the post-discharge period, there was an observed decrease in 30-day COPD index (p = 0.35), HF index (p = 0.23), and all-cause (p = 0.62) readmission rates from pre- to post-intervention. The results of this intervention show that CPS intervention in the post-discharge period may reduce index and all-cause readmission rates for patients discharged with a principle or secondary discharge diagnosis of COPD or HF.

Antihypertensive medication adherence and blood pressure control among central Alabama veterans.

Medication nonadherence is associated with adverse outcomes. To evaluate antihypertensive medication adherence and its association with blood pressure (BP) control, the authors described population adherence to prescribed antihypertensive medication (proportion of days covered ≥80%) and BP control (mean BP <140/90 mm Hg) among central Alabama veterans during the fiscal year 2015. Overall, 75.1% of patients receiving antihypertensive medication were considered adherent, and 66.1% had adequate BP control. Patients adherent to antihypertensive medication were more likely to have adequate BP control compared with patients classified as nonadherent (67.4% vs 62.0%; adjusted odds ratio 1.33; 95% confidence interval, 1.22-1.44 [P<.0001]). Among patients who had uncontrolled BP, 73.6% were considered adherent to medication. Adherence to antihypertensive medication was associated with adequate BP control; however, a substantial proportion of patients with inadequate BP control were also considered adherent. Interventions to increase BP control could address more aggressive medication management to achieve BP goals.

Elevated hepatic transaminases associated with the use of interferon alfacon-1 and ribavirin.

PURPOSE: The case of a patient with hepatitis C who developed elevated hepatic transaminase levels associated with the use of interferon alfacon-1 and ribavirin is described. SUMMARY: A 55-year-old Caucasian man arrived at a hepatitis C clinic to discuss alternative treatment options for his hepatitis C virus (genotype 1a) infection, which did not respond to a 48-week course of peginterferon and ribavirin therapy. He was subsequently treated with interferon alfacon-1 9 microg subcutaneously daily plus ribavirin 200 mg orally twice daily. During treatment with interferon alfacon-1, he developed elevated hepatic transaminase levels despite a decrease in viral load. His hepatic transaminase levels returned to baseline when interferon alfacon-1 was discontinued and rose again upon rechallenge. Ribavirin was not the likely cause of the increase in transaminases since the patient previously tolerated it in combination with peginterferon. While activation of autoimmune hepatitis is a potential cause of acute decompensation in patients treated with interferons, it was not believed to be the case in this patient. Interferon alfacon-1 was determined to be the probable cause of the rise in hepatic transaminase levels in this patient, since his levels declined when therapy was discontinued and rose dramatically once it was restarted. This case illustrates the importance of monitoring both viral loads and hepatic transaminase levels in patients with hepatitis C being treated with interferon therapy. CONCLUSION: A patient with hepatitis C developed elevated hepatic transaminase levels despite showing an improvement in viral load after receiving interferon alfacon-1 and ribavirin.