Eastern Colorado Health Care System Research Articles

A quality improvement project to improve treatment of severe hypertriglyceridemia in veterans.

Severe hypertriglyceridemia (sHTG) is associated with an increased risk of acute pancreatitis. Prompt recognition and treatment of sHTG is key for prevention of acute pancreatitis and its associated life-threatening complications. Patients with sHTG at a primary care clinic within the Veterans Affairs Eastern Colorado Health Care System were receiving suboptimal treatment that did not align with evidence-based guidelines. We initiated a quality improvement (QI) project to improve the management of sHTG in an outpatient primary care clinic. Veterans with a triglyceride level between 500 and 1,500 mg/dl were included in the project. Project interventions included provider education, patient education, and targeted electronic consultations (e-consults) with treatment recommendations. The primary outcome was to decrease the percentage of patients with triglycerides ≥500 mg/dl by 25%. The secondary outcome was to decrease the mean triglyceride level of the patient population by 15%. Education on evaluation and treatment of sHTG was given to 100% (n = 21) of primary care clinicians. Overall, 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received appropriate written education materials, and 72.8% (95% CI [62.6-81.6%]) of patients (n = 67) received a targeted e-consult. The percentage of patients with sHTG decreased by 47%. Average triglyceride level decreased from 651 to 483 mg/dl (25.8% decrease). A multipronged QI project consisting of provider education, patient education, and targeted e-consults resulted in decreased triglyceride levels and improved access to specialist expertise. Clinical implications include decreased prevalence of sHTG and risk of acute pancreatitis among patients in the project.

Description of patient questions received by clinical pharmacists in the Nudge Study.

The Nudge Study is a patient level-randomized trial testing different text message medication refill reminders sent to patients assigned to 4 arms: (1) usual care, (2) generic text, (3) optimized text, and (4) optimized text plus chatbot. This report describes the frequency and types of patient questions sent to clinical pharmacists (CPs) following text reminders. Patients were enrolled from Denver Health and Hospital Authority (DHHA) and Veterans Affairs Eastern Colorado Health Care System (VA ECHCS) from October 1, 2019, through May 30, 2021. Included patients responded to at least 1 text or interactive voice response (IVR) message. Patients were dichotomized as those who posed at least 1 question to a CP and those who posed no questions. Of the 6,325 patients enrolled in an intervention arm, 3,323 (52.5%) responded to at least 1 text or IVR message, and among those responding, 305 (9.2%) responded with a pharmacist question. Patient factors associated with submitting a CP question included age (45-74 years), enrollment from DHHA, and receipt of the optimized text or optimized text plus chatbot message versus the generic text. Questions to CP were in the following categories: medication related (48.2%), refill logistics (38.4%), cost (9.2%), and other (17.7%). In a text messaging intervention focused on medication refills, there were few questions directed to the CP. Patients assigned to receive optimized texts were more likely to have questions. We hypothesize that this may suggest greater patient engagement regarding their condition, resulting in more questions.

A Retrospective Comparison of HIV Pre-exposure Prophylaxis (PrEP) Outcomes Between a Pharmacist-led Telehealth Clinic and In-person Clinic in a Veteran Population.

Pre-exposure prophylaxis (PrEP) reduces human immunodeficiency virus (HIV) transmission through sexual contact by at least 90% when taken as prescribed. This retrospective cohort study evaluated differences in adherence to PrEP medication and monitoring between the physician- and nurse practitioner (NP)-led in-person setting and the pharmacist-led telehealth setting among patients followed by the infectious diseases clinic at the VA Eastern Colorado Health Care System from July 2012 to February 2021. The primary outcomes were PrEP tablets filled per person-year, serum creatinine (SCr) tests per person-year, and HIV screens per person-year. Secondary outcomes included sexually transmitted infection (STI) screens per person-year and patients lost to follow-up.149 patients were included in the study, with 167 person-years in the in-person cohort and 153 person-years in the telehealth cohort. Adherence to PrEP medications and monitoring was similar between in-person and telehealth clinics. PrEP tablets filled per person-year was 324 in the in-person cohort and 321 in the telehealth cohort (RR = 0.99; 95% CI, 0.98-1.00). SCr screens per person-year was 3.51 in the in-person cohort and 3.37 in the telehealth cohort (RR = 0.96; 95% CI, 0.85-1.07). HIV screens per person-year was 3.55 in the in-person cohort and 3.38 in the telehealth cohort (RR = 0.95; 95% CI, 0.85-1.07). There were no new HIV infections. Additionally, patients were less likely to be lost to follow-up when followed via telehealth (11.9% vs. 30.0%), Χ2 (1, N = 149) = 6.85, p = 0.009. These findings indicate that pharmacist-driven delivery of PrEP via telehealth can be used to increase access to PrEP without sacrificing quality of care.

Comparison of hepatitis C treatment outcomes between telehepatology and specialty care clinics in the era of direct-acting antivirals

Introduction Telehealth technologies for rural patients are increasingly being used to deliver care within the Department of Veterans Affairs (VA), and treatment of hepatitis C virus (HCV) is no exception. However, data evaluating outcomes with telehealth compared with specialty clinics in the era of direct-acting antiviral (DAA) agents is sparse. Methods In a retrospective analysis, we compared treatment outcomes for patients receiving DAAs followed solely in a telehepatology clinic (telehealth) versus an in-person specialty care clinic (standard of care) at the VA Eastern Colorado Health Care System. Patients with decompensated cirrhosis (CTP-B or CTP-C) were excluded from the study as they were exclusively followed via standard of care. Provider overlap occurred between clinics and consisted of physician specialists (hepatology and infectious diseases), physician assistants and clinical pharmacists. Results From 1 January 2014 to 31 December 2017, we treated 764 veterans for HCV infection. Standard of care was provided to 629 patients representing 654 treatment courses, and telehealth was provided to 135 patients representing 138 treatment courses. Sustained virologic response rates were not significantly different between the two clinics when looking at total treatment courses (93% telehepatology vs 89% specialty care, p = 0.203) and individual patients treated (95% telehepatology vs 93% specialty care, p = 0.377). Discussion Hepatitis C treatment utilizing telehealth technologies to improve access to care does not negatively impact treatment outcomes when compared with specialty care clinics in the era of DAAs.

Frequency of appropriate lab monitoring of oral chemotherapy in an outpatient setting.

The aim of this study is to understand the frequency of appropriate laboratory monitoring of oral chemotherapy at the Eastern Colorado Health Care System (ECHCS) compared to recommendations set forth in the 2012 Veterans Health Administration (VHA) Guidance on Dispensing and Monitoring of Oral Chemotherapy. This study is a retrospective chart review of patients who have received a subset of oral chemotherapy drugs at ECHCS. Patients 18 to 89 years of age with an active cancer diagnosis who initiated therapy at ECHCS between September 1, 2010 and August 31, 2014 were included in the study. Initial and subsequent prescription fill dates, appropriate labs as defined by VHA guidance and baseline and follow-up lab monitoring dates, and appropriate labs as defined by VHA guidance were collected for up to 12 cycles of chemotherapy per patient. Baseline labs were defined as within three months of the first prescription fill date, and follow-up labs were defined as within seven days of subsequent prescription fill dates. Results are presented as complete, partial, or incomplete and as attempt or no attempt at monitoring according to the VHA guidance recommendations. There was 100% attempt at laboratory monitoring at baseline; however, there was a decline in attempt and complete follow-up monitoring overall as well as for drugs that require special monitoring. Based on recommendations from the 2012 VHA Guidance on Dispensing and Monitoring Oral Chemotherapy, data presented here demonstrate that ECHCS could benefit from improved lab monitoring in order to ensure safe and effective use of oral chemotherapies. These results provide a unique opportunity to consider the potential role of clinical pharmacists in monitoring and management of patients receiving oral chemotherapies as well as patient and provider education regarding the importance of appropriate lab monitoring.

The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care

BackgroundVeterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans’ social determinants of health (SDOH) to facilitate Veterans’ transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care.MethodsThe ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams.We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping.DiscussionThe ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans’ SDOH. This intervention will provide an essential service for effective care coordination.

MON-099 Age-Related Differences in Appetite Regulation among Adults with Obesity: More Than Just Hunger and PYY and Ghrelin? Oh My!

Background: There is evidence that the regulation of energy intake (EI) changes with aging. The “anorexia of aging” is defined as the reduction of hunger and EI in late life. Yet, despite decreased EI and weight loss, obesity has also increased among the geriatric population. With few studies in older adults with obesity, we aimed to address this paradox by evaluating age-related differences in appetite regulation. Hypotheses: We hypothesized that there is decreased ad libitum EI in older adults with obesity (OOb) as compared to younger adults with obesity (YOb), related to decreased subjective appetite and eating-related behaviors, and differences in appetite-related peptides. Methods: We performed a cross-sectional pilot study in OOb aged 65-85 years as compared to YOb aged 21-45 years, all with BMI 30-40 kg/m2. Appetite-related ratings and peptides, eating-related behaviors and ad libitum EI in OOb were compared to YOb. Exclusions included comorbidities and medications that affect appetite and weight, tobacco or marijuana use, body weight >300 lbs, or weight loss in the past 6 months. Appetite (Visual Analogue Scales for hunger and satiety) and hormones (ghrelin, peptide YY [PYY] and glucagon-like peptide-1 [GLP-1]) were measured in the fasted state and every 30 minutes for 3 hours following a test breakfast meal. Eating behaviors and ad libitum EI at a lunch meal were also measured. Results: Data from 6 OOb and 15 YOb were analyzed (age 71±3 vs. 35±8 yrs, p<0.001, respectively). BMI was similar (OOb 32.8±1.2 vs. YOb 32.6±0.5 kg/m2, p=0.85) as was % body fat (OOb 39.8±2.4 vs. YOb 41.4±1.5 %, p=0.58). Ad libitum EI was similar though it trended to be higher in OOb (OOb 784±66 vs. YOb 645±48 kcals, p=0.10). Hunger area under the curve (AUC) was lower in OOb (OOb 3,702±1,004 vs. YOb 5,654±432 mm, p=0.04). PYY AUC was higher (OOb 26,419±2,501 vs. YOb 20,894±1,277 pg/mL, p=0.04) and ghrelin AUC trended to be lower in OOb (OOb 109,772±6,689 vs. YOb 132,360±8,616 pg/mL, p=0.08). Differences in satiety AUC (OOb 9,174±1,150 vs. YOb 8,580±363 mm, p=0.52), food cravings (OOb 32.2±3.7 vs. YOb 39.7±2.8, p=0.11), restraint (OOb 11.0±1.3 vs. YOb 9.5±1.0, p=0.37), disinhibition (OOb 5.6±1.3 vs. YOb 6.9±1.0, p=0.30), leptin (OOb 46.4±18.6 vs. YOb 64.0±8.9 ng/mL, p=0.34) and GLP-1 (OOb 2,995±874 vs. YOb 994±381 pmol/L, p=0.11) were not statistically significant. Conclusions: Despite a trend toward higher ad libitum EI, OOb had lower hunger, higher PYY and possibly lower ghrelin than YOb. There appear to be age-related mechanistic differences in appetite regulation between older and younger adults with obesity that deserve further investigation, with implications for more tailored obesity treatments. Research Support: NIH Grant T32, ADA Translational Science Award, VA Eastern Colorado Health Care System GRECC Pilot Project and Fellowship

Impact of multidisciplinary chart reviews on opioid dose reduction and monitoring practices

IntroductionThe Veterans Affairs (VA) Eastern Colorado Health Care System implemented an Opioid Safety Initiative (OSI); this included multidisciplinary chart reviews of patients with chronic, non-malignant pain on high-dose opioid therapy to provide safety recommendations to prescribers through the electronic medical record. Our study objective was to evaluate the impact of these documented recommendations. Outcomes included change in total daily opioid dose, concurrent prescribing of opioids and benzodiazepines, adherence to local VA/Veterans Integrated Service Network (VISN) policy, and monitoring practices. MethodsThis retrospective chart review of patients prescribed ≥200 mg of morphine equivalent daily dose (MEDD) collected data from OSI chart reviews conducted between January 1, 2015 and March 31, 2015. Outcomes were assessed during the 12 months following initial review. Primary outcomes included: opioid dose reduction, discontinuation of concurrent benzodiazepines, and adherence to VA/VISN policy, including documentation of signed informed Consent for Long-Term Opioid Therapy for Pain, biannual urine drug screens (UDS), and follow-up every six months with primary opioid prescriber. ResultsOf 147 patients meeting inclusion criteria, 50 patients (34%) reduced opioid dose with the baseline median MEDD decreasing from 315 mg to 278 mg. Of the 48 patients prescribed benzodiazepines and opioids, 10 patients discontinued benzodiazepines (21%). Completion of informed consents increased from 31% to 48%, biannual UDS increased from 44% to 61%, and follow-up with opioid prescriber was unchanged. ConclusionAfter completion of OSI chart reviews, reduction in opioid dose and concurrent prescribing of benzodiazepines was observed. VA/VISN policy and monitoring adherence also showed improvement.

Study protocol: improving the transition of care from a non-network hospital back to the patient\u2019s medical home

BackgroundThe process of transitioning Veterans to primary care following a non-Veterans Affairs (VA) hospitalization can be challenging. Poor transitions result in medical complications and increased hospital readmissions. The goal of this transition of care quality improvement (QI) project is to identify gaps in the current transition process and implement an intervention that bridges the gap and improves the current transition of care process within the Eastern Colorado Health Care System (ECHCS).MethodsWe will employ qualitative methods to understand the current transition of care process back to VA primary care for Veterans who received care in a non-VA hospital in ECHCS. We will conduct in-depth semi-structured interviews with Veterans hospitalized in 2015 in non-VA hospitals as well as both VA and non-VA providers, staff, and administrators involved in the current care transition process. Participants will be recruited using convenience and snowball sampling. Qualitative data analysis will be guided by conventional content analysis and Lean Six Sigma process improvement tools. We will use VA claim data to identify the top ten non-VA hospitals serving rural and urban Veterans by volume and Veterans that received inpatient services at non-VA hospitals.Informed by both qualitative and quantitative data, we will then develop a transitions care coordinator led intervention to improve the transitions process. We will test the transition of care coordinator intervention using repeated improvement cycles incorporating salient factors in value stream mapping that are important for an efficient and effective transition process. Furthermore, we will complete a value stream map of the transition process at two other VA Medical Centers and test whether an implementation strategy of audit and feedback (the value stream map of the current transition process with the Transition of Care Dashboard) versus audit and feedback with Transition Nurse facilitation of the process using the Resource Guide and Transition of Care Dashboard improves the transition process, continuity of care, patient satisfaction and clinical outcomes.DiscussionOur current transition of care process has shortcomings. An intervention utilizing a transition care coordinator has the potential to improve this process. Transitioning Veterans to primary care following a non-VA hospitalization is a crucial step for improving care coordination for Veterans

MRSA colonization and the nasal microbiome in adults at high risk of colonization and infection

The objective of this study was to define the nasal microbiome of hospital inpatients who are persistently colonized with methicillin-resistant Staphylococcus aureus (MRSA) compared with matched, non-colonized controls. Twenty-six persistently MRSA-colonized subjects and 26 matched non-colonized controls were selected from the screening records of the infection control program at the Department of the Veteran Affairs Eastern Colorado Health Care System (VA-ECHCS). The nasal microbiotas were analyzed with PCR amplification and sequencing of the 16S ribosomal RNA (rRNA) gene. Comparison of all variables across the groups was performed using stratified logistic regression to account for the one-to-one matching. Canonical discriminant analysis was performed to assess differences in bacterial community across the two groups. Competing organisms were cocultured with MRSA in vitro. There was a negative association between MRSA colonization and colonization with Streptococcus spp. At the species level, multivariate analysis demonstrated a statistically significant negative association between colonization with Streptococcus mitis or Lactobacillus gasseri and MRSA. Coculture experiments revealed in vitro competition between S. mitis and all of the 22 MRSA strains isolated from subjects. Competition was blocked by addition of catalase to the media. Persistently colonized subjects had lesser microbial diversity than the non-colonized controls. In a high-risk inpatient setting, bacterial competition in the nasal niche protects some patients from MRSA colonization.

Evaluation of a prior authorization policy on compliance with VA pharmacy benefits management services recommendations for antipsychotic selection

Abstract Introduction: A previous study at Veterans Affairs (VA) Eastern Colorado Health Care System revealed low rates of compliance with VA Pharmacy Benefits Management Services recommendations for antipsychotic selection in schizophrenia and schizoaffective disorders. As a result, formulary restrictions of second-line antipsychotics were implemented. Since April 2013, new starts of second-line antipsychotic agents require a prior authorization drug review. The objectives of this study were to evaluate the impact of the prior authorization process on compliance with the VA criteria for prescribing aripiprazole, olanzapine, and ziprasidone. The primary objective was to compare compliance rates with VA antipsychotic selection criteria preimplementation and postimplementation of the prior authorization drug review policy. Methods Single center, retrospective chart review of patients receiving aripiprazole, olanzapine, and ziprasidone. A report of all patients receiving a prescription for the above 3 agents between April 8, 2013, and December 6, 2013, was generated from the electronic medical record system. Charts were reviewed manually to determine compliance. Results One hundred forty-two unique patients were started on aripiprazole, olanzapine, and/or ziprasidone. Ninety percent of patients met VA criteria for use of these second-line antipsychotic agents, compared to 26% of patients prior to implementation of the prior authorization drug review. Overall prescribing of these agents decreased by 60%, resulting in an estimated cost avoidance of $617 389. Discussion Implementation of a prior authorization drug request for aripiprazole, olanzapine, and ziprasidone was associated with increased compliance with VA criteria for use of antipsychotic agents and with marked cost avoidance due to the reduced use of more expensive second-line antipsychotic agents.

1143

1University of Colorado Health Sciences Center, Department of Anesthesiology, Aurora, CO 2VA Eastern Colorado Health Care System, Department of Anesthesiology, Denver, CO

Virtual Rapid Response

The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center’s tele–intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a “virtual handshake” by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19’s medical centers.

Virtual Rapid Response

The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center's tele-intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a "virtual handshake" by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19's medical centers.

Sustaining Caring Change in a Healthcare System

In 2003, nursing leaders from the Eastern Colorado Health Care System (ECHCS) integrated caring theory-guided practice on 4South, a busy %bed surgical telemetry unit. The endeavor was documented in the 2005 article, Being and Creating Caring Change in a Healthcare System (Bent et al., 2005). Since then, there have been successes and challenges in sustaining an atmosphere based on the implemented changes. This article serves as a follow up to the creation of the Nightingale Unit. We will outline the conscious efforts and actions on 4outh over 6 years and discuss future goals for this innovative unit.

Disposal of a 60Co Self-Shielded Irradiator Through The Department of Energy’s Off-Site Source Recovery Project

An Atomic Energy of Canada Limited Gamma Cell 220 self-shielded irradiator acquired in 1974 by the VA Eastern Colorado Health Care System was disposed of through the Department of Energy's Off-Site Source Recovery Project in 2006.

Being and Creating Caring Change in a Healthcare System

Nursing leaders from the VA Eastern Colorado Health Care System (VAECHCS) developed an evolving model of caring theory-guided practice. As leaders and administrators with multiple roles, functions, and perspectives in a large healthcare system, the authors create and hold space for human caring and relationship-centered care within a clinical practice setting. This article contributes an overview of their action research framework and how they use this framework to link practice, theory, and inquiry in the delivery of healthcare services.