VA Pittsburgh Healthcare System Research Articles

Quality Assessment/Quality Improvement Measures for the Neurological Care of the Post Cardiac Arrest Patient at VA Pittsburgh Health Care System (P4-15.004)

Quality Assessment/Quality Improvement Measures for the Neurological Care of the Post Cardiac Arrest Patient at VA Pittsburgh Health Care System (P4-15.004)

1046-P: ELEGANT-DM2—Early Intervention Addressing Therapeutic Inertia in Diabetes Mellitus-2

Primary care (PC) models for DM2 care driven by clinical pharmacists (CPs) have shown benefits, while access to a diabetologist (DCS) for patients with complex DM2 is limited. A prospective observational study at VA Pittsburgh Healthcare System studied the impact of a novel collaborative care model: ELEGANT-DM2 used a diabetes dashboard (DD) to identify patients with clinical therapy inertia (CTI) and weekly virtual huddles linking CPs in PC with a DCS for case review and recommendations. Using a DD, 103 patients with DM2 and A1c>9% were enrolled between 09/2020 to 03/2021 and received the collaborative care intervention over 12 months. Patient demographics, comorbidities, A1c at 12-months (PRE-12) pre-enrollment, enrollment (E), and 12 months (PS-12) post-enrollment, and diabetes medications at E and PS-12 were extracted. A non-parametric test was used to compare continuous outcome measures (Mean+/-SD); categorical measures as percentages. McNemar test was used to conduct pre-post proportion comparisons in specific cohorts for SGLT-2i and GLP-1RA medications. The study cohort was mostly male (94%), white (90%), with a mean age of 69.3 years, had pre-existing CVD (91%), obesity (89%), HTN (87%), CKD (16%), and CHF (10%). A significant rise in A1c was noted from 9.3% (+/-1.4) at Pre-12 to 10.8% (+/-1.5) at E (p=.008). A significant decline was noted in A1c from 10.8% (+/- 1.5) at E to 8.2% at PS-12 (p=<0.001). In patients with DM2 and CVD, use of SGLT-2i and GLP-1RA increased significantly (SGLT-2i: 16.5% at E to 29% at PS-12, p=0.009; GLP-1A: 20% at E to 36% at PS-12, p=.003). In patients with DM2 and obesity, GLP-1RA use increased from 18.2 % at E to 39.4% at PS-12 (p=.0008). A non-significant increase in the use of SGLT-2i was seen in cohorts with CKD and CHF. ELEGANT-DM2 identified CTI using DD, eliminated the traditional referral process, led to therapy optimization via virtual huddles between PC CPs and DCS, and delivered sustained improvement in DM2 control and uptake of new medications Disclosure A.Bandi: None. D.Becker: None. S.Sodders: None. M.Zupa: None. J.L.Mccoy: None. N.M.Pertinaci: None. M.Y.Boudreaux-kelly: None. Funding Office of Health Equity (SPRV-OHEA160)

Expanding veteran treatment access points through Close To Me (CTM) infusion service.

1519 Background: Diagnosing and treating more than 43,000 Veterans annually, the Veterans Affairs (VA) National Oncology Program (NOP) oversees the largest integrated providers of hematology/oncology services in the US. Within the VA, parenteral therapies are primarily offered at VA Medical Centers (VAMC) in urban areas, often inaccessible to rural patients. Travel distance, parking, time, and caregiver support can prevent patients from adhering to treatment regimens. To resolve these challenges, NOP launched the Close to Me (CTM) infusion service. The service seeks to reduce travel time for patients, improve VA care continuity, and increase access points to patient-centric care by administering treatments utilizing the network of VA Community Based Outpatient Clinics (CBOC). Methods: In the CTM CBOC infusion service select medications are compounded at the main VAMC, then transported via a registered nurse to the surrounding CBOCs for administration. Eligible patients must be established with a VA hematologist/oncologist and tolerated 1 cycle of treatment at the VAMC. Patients are assessed via telehealth prior to each treatment at the CBOC. Patient drive miles saved was calculated by subtracting the mileage between the patient’s home address and the CBOC from the patient’s home address and the VAMC, then multiplied by number of treatment visits at the CBOC. Medication cost avoidance was calculated by subtracting the VA purchase price from the 2023 published Centers for Medicare and Medicaid Services reimbursement rates, then multiplied by number of treatments received at the CBOC. The first CTM CBOC clinics were opened within the Minneapolis VA Health Care System in October 2021, followed by the VA Pittsburgh Healthcare System in June 2022. Results: From October 2021 through December 2022, 373 unique patients were treated within CTM CBOC clinics for a total of 532 patient visits. The CTM infusion service resulted in 43,249 patient drive miles saved and 813,352 in medication cost avoidance. No medical emergencies were reported during CTM CBOC treatments. One medication was discarded without use due to damage during shipping. One compounded product was not used due to change in patient status. One patient was non-adherent with treatment appointments on two occasions resulting in an overall 99.6 % treatment adherence. Conclusions: The CTM infusion service optimizes current VA infrastructure to increase access points to hematology/oncology treatment, reduce travel burden for patients, increase treatment appointment adherence and reduce medication cost expenditures. To facilitate expansion of this successful service, NOP has provided funding and support to 11 additional VAMCs to implement one of the CTM solutions including CBOC, mobile infusion unit or home infusion. A comprehensive implementation toolkit was developed to encourage the independent adoption of this service at appropriate locations across VA.

0833 Acceptability of the Transdiagnostic Behavioral Sleep and Circadian Intervention to Individuals in Cardiac Rehabilitation

Abstract Introduction Sleep health is often compromised among individuals undergoing cardiac rehabilitation and does not consistently improve over the course of treatment. Behavioral sleep and circadian interventions may improve the sleep health of cardiac rehabilitation patients but have not been widely tested in this context. We conducted a preliminary test of an adapted version of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) with Veterans in cardiac rehabilitation to evaluate its acceptability with these unique patients. Methods Eight Veterans with sleep disturbance and/or sleep-related impairment who were participating in outpatient cardiac rehabilitation completed the adapted TranS-C intervention and post-intervention acceptability measures. Intervention acceptability was assessed quantitatively with subscales from the Multidimensional Treatment Satisfaction Measure (subscale scores range from 0-4; higher scores indicate greater satisfaction) and qualitatively via semi-structured interviews. We calculated descriptive statistics for quantitative measures and analyzed semi-structured interviews using a rapid qualitative analysis approach. Results Participants felt the intervention was suitable to their needs (M=3.00, SD=.94) and useful for increasing their knowledge and understanding of sleep problems and how to manage them (M=3.50, SD=.69). Participants endorsed positive attitudes toward the intervention (M=3.63, SD=.58) and high likelihood of recommending the intervention to others similarly experiencing sleep problems (M=3.63, SD =.58). Following the intervention, 62.5% of participants indicated that their sleep disturbance and sleep-impairment were ‘much better’ than at the first study visit and 37.5% indicated their sleep disturbance and sleep-related impairment were ‘somewhat better’. Qualitative findings converged with the noted quantitative findings. Conclusion Veteran cardiac rehabilitation patients expressed satisfaction and positive attitudes toward the adapted TranS-C intervention. All participants reported subjective post-intervention improvements in sleep disturbance and sleep-related impairment. These findings provide preliminary support for further large-scale testing of adapted TranS-C in cardiac rehabilitation. Support (if any) Dr. Tighe is supported by a Career Development/Capacity Building Award (IK2 RX003393) from the United States Department of Veterans Affairs Rehabilitation R&D (Rehab RD) Service. This material is the result of work supported with resources and use of facilities at the VISN 4 Mental Illness Research, Education, and Clinical Center at VA Pittsburgh Healthcare System.

A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center

Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table. A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention. To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.

A Program to Reduce Post-Operative Opioid Prescribing at a Veteran’s Affairs Hospital

Variability in surgeon prescribing patterns is common in the post-operative period and can be the nidus for dependence and addiction. This project aims to reduce opioid overprescribing at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS). The VAPHS Opioid Stewardship Committee collaborated to create prescribing guidelines for inpatient and outpatient general, thoracic, and vascular surgery procedures. We incorporated bundled order sets into the provider workflow in the electronic medical system and performed a retrospective cohort study comparing opioid prescription patterns for Veterans who underwent any surgical procedure for a three-month period pre- and post- guideline implementation. After implementation of opioid prescribing guidelines, morphine milligram equivalents (MME), quantity of pills prescribed, and days prescribed were statistically significantly reduced for procedures with associated guidelines, including cholecystectomy (MME 140.8 vs. 57.5, p = 0.002; quantity 18.8 vs. 8, p = 0.002; days 5.1 vs. 2.8, p = 0.021), inguinal hernia repair (MME 129.9 vs. 45.3, p = 0.002; quantity 17.3 vs. 6.1, p = 0.002; days 5.0 vs. 2.4, p = 0.002), and umbilical hernia repair (MME 128.8 vs. 53.8, p = 0.002; quantity 17.1 vs. 7.8, p = 0.002; days 5.1 vs. 2.5, p = 0.022). Procedures without associated recommendations also preceded a decrease in overall opioid prescribing. Post-operative opioid prescribing guidelines can steer clinicians toward more conscientious opioid disbursement. There may also be reductions in prescribing opioids for procedures without guidelines as an indirect effect of practice change.

An Academic Hospitalist–Run Outpatient Paracentesis Clinic

Patients needing large-volume paracenteses (LVPs) can occupy inpatient hospital beds and unnecessarily use inpatient resources.We describe an outpatient paracentesis clinic that was part of a quality assurance initiative at the Veterans Affairs Pittsburgh Healthcare System in Pennsylvania. A retrospective review was conducted that included patient age, sex, etiology of ascites, amount of ascites removed, time of the procedure, complications, and results of ascites cell count and cultures abstracted from the electronic health record.Over 74 months, 506 paracenteses were performed on 82 patients. The mean volume removed was 7.9 L, and the mean time of the procedure was 33.3 minutes. There were 5 episodes of postprocedure hypotension that required admission for 3 patients. One episode of abdominal wall hematoma occurred that required admission. Two patients developed incarceration of an umbilical hernia after the paracentesis; both required surgical repair. Without the clinic, almost all the 506 outpatient LVPs we performed would have resulted in a hospital admission.An outpatient paracentesis clinic run by academic hospitalists can safely and quickly remove large volumes of ascites and minimize hospitalizations.

Exploring Research Engagement and Priorities of Transgender and Gender Diverse Veterans.

In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings. From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study. Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g., LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research. By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings.

The Effect of Radium-223 Therapy in Agent Orange-Related Prostate Carcinoma.

Radium-223 (Ra-223) radioisotope has been reported to increase median survival in bone metastatic prostate carcinoma. The addition of Ra-223 to abiraterone was associated with an increased risk of bone fractures. There has been no comprehensive data for using Ra-223 in veterans who were exposed to Agent Orange (AO+). We present a retrospective study of veterans with bone metastatic castration-resistant prostate cancer (CRPC) who received standard doses of Ra-223 and other sequential therapies at US Department of Veterans Affairs Pittsburgh Healthcare System in Pennsylvania from January 2014 to January 2019. Veterans were divided into 2 groups: those who were exposed to Agent Orange (AO+) and those who had no exposure (AO-). Time to study was calculated from the initiation of Ra-223. Time to skeletal-related events (SRE), progression of prostate specific antigen (PSA), bone metastasis, and alkaline phosphatase (ALP) were calculated in months using unpaired t test with 2-tailed P values. Median survival was calculated by Kaplan Meier R log-rank test. There were 34 veterans with bone metastatic CRPC: 17 veterans (50%) were AO+ and 17 veterans (50%) were AO-. The mean age of diagnosis of AO+ veterans was 62 years and 69 years (P = .005) for AO- veterans (the mean Gleason score 8.2 and 8.0, respectively [P = .71]). The median number of Ra-223 cycles was 6 (60%). Ten veterans received Ra-223 as first line (29%) and 24 veterans received Ra-223 later (71%). There were 12 SREs with median survival of 15 months. There was no difference in mean time to SRE between AO+ (8 veterans, 10.6 months) and AO- (4 veterans, 10.3 months) (P = .93). The mean time to PSA progression for AO+ was 5.4 months and AO- was 6.8 months (P = .28). Mean time to bone progression for AO+ was 7.6 months and AO- was 10.1 months (P = .16). Mean time to ALP progression for AO+ and AO- was 6.3 months and 8.7 months, respectively (P = .05). Twenty veterans (58%) had died. Median survival for Ra-223 first was 32 months and for Ra-223 later was 15 months (P = .14; hazard ratio [HR] 0.48; 95% CI, 0.17-1.3). Median survival for AO+ and AO- veterans was 12 months and 18 months, respectively (P = .15; HR, 2.0; 95% CI, 0.77-5.0). There was no statistical difference between AO+ and AO- veterans in terms of time to SRE, PSA, bone and ALP progression, even though there was a trend of shorter duration in AO+ veterans. There was no median survival difference between Ra-223 first vs Ra-223 later as well as between AO+ and AO- but there is a trend of worse survival in AO+ veterans.

Cardiac Rehabilitation Has Important Benefits for Both HFpEF and HFrEF Patients

Introduction The benefits and safety of cardiac rehabilitation (CR) for heart failure with reduced ejection fraction (HFrEF) demonstrated in research studies led to the decision by the Centers for Medicare & Medicaid Services (CMS) to fund CR for HFrEF. Evidence of the value of CR for heart failure with preserved ejection fraction (HFpEF) remains limited, and CR funding for HFpEF has not been approved by CMS. Many HFpEF patients are older and functionally impaired, therefore, theoretical rationale for exercise training in HFpEF remains compelling. At VA Pittsburgh Healthcare System (VAPHS), we compared HFrEF and HFpEF patients participating in CR. Methods HFrEF and HFpEF patients enrolled in a phase II CR program were compared. Thirty-two HF patients (19 HFrEF, 13 HFpEF) enrolled in the VAPHS Cardiac Rehab program completed post-CR assessments of physical function. Improvements in 6 Minute Walking Distance (6MWD) are described as mean + standard deviation (SD) and assessed with paired t-tests. Results CR was uniformly safe and well tolerated. Baseline data show HFpEF and HFrEF patients with significant functional impairments (HFpEF> HFrEF) including strength, balance, aerobic, and frailty domains. In all cases, HFpEF patients were more compromised than HFrEF (Table). Both HFpEF and HFrEF achieved clinical improvements in all domains through CR, including significant gains in 6MWD. Conclusion HFpEF patients start CR with worse functional status but derive similar benefits from CR as HFrEF patients. Further consideration should be given to reimbursement for CR in HFpEF patients.

Creation of a virtual cancer care network for remote oncology treatment.

6546 Background: The VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Network was launched in January 2018 after we had established an electronic consult service where 555 hematology electronic consults were completed at VAPHS in FY17. The clinical video telehealth (CVT) clinic allows veterans from central Pennsylvania to receive their anticancer therapy at the VA in Altoona, Pennsylvania where the oncology pharmacy, nursing, telehealth, and supportive oncology staff are on site. Patients follow regularly and remotely during treatment via CVT visits with their oncologist located 93 miles away at the VA in Pittsburgh. Methods: A chemotherapy pharmacy and nursing infusion clinic were created at the VA in Altoona. CVT visits started in January 2018. Data including treatment, adverse events defined through CTCAE v5.0, gender, age, zip code, and other details were examined retrospectively. Results: 279 CVT visits for 89 patients were completed January 2018 through Sept 2018. 87 were male, 2 were female. Average age was 70 (range 45-90). Most common primary disease sites were prostate (19.1%), colorectal (13.4%), and lung (9%). 61.8% of patients were on treatment. Non-treatment visits were for surveillance and survivorship. Treatment administered included platinum doublets, fluorouracil doublets, immunotherapy, and oral anticancer therapy. 5.4% of patients had Grade 3-4 events due to febrile neutropenia, increased liver enzymes, and hemolytic anemia. 41.7% had grade 1-2 events due to peripheral neuropathy, neutropenia, anemia, thrombocytopenia, and infusion-related reactions. Using an average commuting speed of 60 mph and a travel cost of $ 0.56 per mile, the total commute distance averted was 49,579 miles. Mean distance averted per patient was 557 miles. Total commute time saved for veterans was 826 hours. Total mileage costs saved for veterans was $27,764. Conclusions: The Virtual Cancer Care Network reduced the travel time and costs for veterans who previously would have travelled from central Pennsylvania to VAPHS for their oncology treatment. Adverse events were tolerable and managed by the VA in Altoona. Integration of CVT secures safe access to cancer care and maintains patients’ primary relationships with their oncologists.

Structural fragmentation of linguistic brain networks predicts aphasia severity, but not response to treatment.

Structural fragmentation of linguistic brain networks predicts aphasia severity, but not response to treatment.

227. Provider Education Paired With Peer Comparison Demonstrates Sustained Reduction in Overall Antibiotic Prescribing Within a Veterans Affairs Primary Care System

BackgroundData on antimicrobial stewardship (AS) interventions in outpatient primary care settings and optimal strategies to sustain results are lacking. We report results of a comprehensive outpatient AS intervention that included provider education and peer comparison.MethodsBaseline antibiotic prescribing data from primary care clinics at VA Pittsburgh Healthcare System from January to April 2016 were collected. Educational sessions were offered to all primary care providers (PCPs) in December 2016. During an intervention period from January to April 2017, PCPs were emailed monthly comparisons of their antibiotic prescribing rate, peer rates, and a system target. Postintervention overall antibiotic prescribing rates from January to April 2018 were assessed. The decision-support software was updated after the intervention to reflect AS team guidance.ResultsDuring the postintervention period, 626 antibiotic prescriptions were written by 73 PCPs caring for 40,428 patients, compared with 1,585 antibiotic prescriptions written by 65 PCPs caring for 40,734 patients during the baseline period and 1,131 antibiotic prescriptions written by 73 PCPs caring for 41,191 patients during the intervention period (P = 0.0002). There were significantly fewer antibiotic prescriptions written during the intervention period than the baseline period (P = 0.0286), and during the postintervention period than the intervention period (P = 0.0286). Azithromycin use decreased by 45.9% (458 vs. 248 prescriptions, P < 0.0001) from the baseline to the intervention period and further decreased by 51.2% (248 vs. 121 prescriptions, P < 0.0001) from the intervention period to the postintervention period. Fluoroquinolone use decreased by 55.6% (160 vs. 71 prescriptions, P < 0.0001) from the baseline to the intervention period, and remained low during the postintervention period (71 vs. 72 prescriptions, P = 0.88).ConclusionA comprehensive AS intervention including provider education and peer comparison demonstrated a sustained reduction in overall antibiotic prescribing rates among PCPs. The decision-support software may assist in maintaining reduced prescribing rates. A full data analysis to include an assessment of appropriateness during each period is ongoing. Disclosures All authors: No reported disclosures.

1529. Suprapubic Catheter Placement Improves Antimicrobial Stewardship in a Veterans Affairs Long-term Care Facility

BackgroundIt is unknown if suprapubic catheters (SCs) offer benefit over indwelling urethral catheters (IUCs) in incidence of asymptomatic bacteriuria and catheter-associated infection (CAUTI), or subsequent antibiotic exposure.MethodsWe conducted a retrospective cohort study of unique patients with SCs placed at VA Pittsburgh Healthcare System from February 2015 to March 2018, who had a prior IUC (≥30 days for each). Demographic, laboratory, microbiologic, and antibiotic use data were compared over the same number of days between IUC and SC periods. IDSA Guidelines were used to define CAUTI and asymptomatic bacteriuria.ResultsEighteen patients with SC were included. SCs were in place for a median of 213 days (range: 49–1,085). The indications for catheterization were urinary retention (n = 12), neurogenic bladder (n = 5), and decubitus healing (n = 1). The most common underlying conditions were benign prostatic hyperplasia (n = 9), multiple sclerosis (n = 2), and Parkinson’s disease (n = 2). The median number of urine cultures collected per 100 IUC and 100 SC days were 2.28 (range: 0–4.08) and 0.35 (range: 0–5.85), respectively (P = 0.02). Forty-four percent (8/18) and 39% (7/18) received at least one antibiotic course for asymptomatic bacteriuria during IUC and SC periods. A total of 170 days of antibiotic therapy were given for asymptomatic bacteriuria per 4,881 IUC days vs. 107 days for asymptomatic bacteriuria per 4,881 SC days (P = 0.0001). The median rate of CAUTI was 0.25 per 100 IUC days vs. 0.08 per 100 SC days (P = 0.15). The most common pathogens causing CAUTIs were Pseudomonas aeruginosa (n = 5), Candida albicans (n = 2), Klebsiella pneumoniae (n = 1) and Enterococcus faecalis (n = 1). A total of 163 days of antibiotic therapy were given for CAUTI per 4,881 IUC days vs. 38 days of antibiotic therapy for CAUTI per 4,881 SC days (P < 0.0001).ConclusionSCs were associated with significantly less overall antibiotic exposure than IUCs, both as treatment of CAUTIs and as inappropriate agents against asymptomatic bacteriuria. CAUTI rates were similar among patients with SCs and IUCs, although cultures were performed more often in those with IUCs. Reducing the treatment of asymptomatic bacteriuria remains a leading stewardship challenge.Disclosures All authors: No reported disclosures.

Development of a virtual cancer care network for distance oncology treatment.

270 Background: The VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Network was launched in January 2018 as the next step after we had established an electronic consult service where 555 hematology electronic consults were completed at VAPHS in FY17. The clinical video telehealth (CVT) clinic allows veterans from central Pennsylvania to receive their anticancer therapy at the VA in Altoona, Pennsylvania where the oncology pharmacy, nursing, telehealth, and supportive oncology staff are on site, while the patients continue to follow regularly during treatment via CVT visits with their oncologist located 93 miles away at the VA in Pittsburgh. Methods: A chemotherapy pharmacy and nursing infusion clinic were created at the VA in Altoona. CVT visits started in January 2018. Data including zip code and clinic visit details were examined through descriptive statistics. Results: A total of 89 CVT visits for 27 patients were completed from January 2018 to May 2018. All patient visits were follow-ups while patients were receiving active treatment. 16 patients received intravenous treatments, and 11 received oral anticancer therapy. 100% of the patients were male. Median age was 73 (range 56-89). The most common diagnosis was prostate cancer (26%). The majority of the patients were receiving therapy for palliative intent. 100% of patients chose VA Altoona rather than VAPHS as their treatment clinic location. Five oncology physicians and one oncology clinical nurse specialist completed the clinical video telehealth visits from VAPHS. Total commuting distance averted was 14,828 miles. With an average commuting speed of 60 mph and a travel cost per mile of 0.5 dollars, the total commute time saved for veterans was 247 hours, and the total mileage costs saved was $7414. Appointment compliance was 100%, and there were no missed opportunities. Conclusions: Implementing the Virtual Cancer Care Network has decreased the travel time and costs for veterans who previously would have travelled from central Pennsylvania to VAPHS for their oncology treatment. The integration of CVT technology has improved patient access to oncology care and maintains the patients’ primary relationships with their oncologists.

Comparison of E-Consults and Face-to-Face Care on Costs and Glycemic Control among Veterans with Type 2 Diabetes Mellitus

Electronic Consults (EC) offer enhanced access to endocrinologists for patients with type 2 diabetes mellitus (T2DM). The effects of EC on costs of care and glycemic control compared to Face-to-Face (F2F) visits are unknown. A retrospective chart review was conducted for Veterans who received EC (n=440) or F2F (n=397) care for T2DM through the VA Pittsburgh Healthcare System (VAPHS) from 2010 to 2015. Data on demographics, rurality, days to consult completion, and percent (%) A1C at baseline and post-consult at 3-6, and 12 months were collected. A web-based tool calculated the average round-trip distance in miles and travel time in hours from patient’s residential zip code to VAPHS. Annual travel costs for recommended 3 visits per year were estimated at a reimbursement rate of $0.415 per mile. Continuous measures (mean ± standard deviation) were compared using Wilcoxon rank-sum tests. Categorical measures (sex, rurality) were presented as percentages and compared between groups by time point using chi-square tests. Veterans who received EC were predominantly male (98.4%), younger (64.2±8.5 years) and rural (15.8%) than those who received F2F care (95.3% male, p=0.01; 68.1±8.7 years, p&amp;lt;0.0001; 3.7% rural, p&amp;lt;0.0001). The EC cohort had shorter consult completion time than the F2F cohort (EC: 10±10 days, F2F: 37±33; p&amp;lt;0.0001). Mean annual travel-related savings per Veteran in the EC cohort were 431±297 miles, 9.4±7 hours, and $179±123. Mean annual travel burden per Veteran in the F2F cohort were 159±171 miles, 3.5±4 hours and $66±71. EC and F2F cohorts had similar baseline A1C values (10%±1.6). Both cohorts had decline in baseline percent A1C to 3- 6 months (EC: 8.98%±1.54, F2F: 8.75%±1.77, p=0.03) and from baseline percent A1C to 12 months (EC: 8.80%±1.61, F2F: 8.57%±1.72, p=0.002). Electronic consults deliver effective and expedient care by saving money and travel time, and offer long-term, sustainable glycemic control comparable to F2F care for patients in remote areas with T2DM. Disclosure N. Karajgikar: None. K.B. Detoya: None. J.N. Beattie: None. S.J. Lutz-McCain: None. M.Y. Boudreaux-Kelly: None. A. Bandi: None.

Meta-analysis of Treatment of Underlying Forms: dosage-related and person-level predictors of acquisition and generalization response

Meta-analysis of Treatment of Underlying Forms: dosage-related and person-level predictors of acquisition and generalization response

Primary Care and Hepatology Provider-Perceived Barriers to and Facilitators of Hepatitis C Treatment Candidacy and Adherence.

Provider perceptions regarding barriers to and facilitators of hepatitis C (HCV) treatment initiation and adherence have not been fully evaluated in the interferon-free treatment era. New treatments have provided opportunities for non-specialists to treat HCV, underscoring the importance of understanding primary care provider (PCP) and specialist perspectives. Based on qualitative sampling principles, 12 PCPs and 12 hepatology providers (HPs) from the VA Pittsburgh Healthcare System completed audio-recorded semi-structured interviews. Qualitative analysts coded perceived barriers and facilitators from the interviews with 100% double coding. Codes were thematized and analyzed using Atlas.ti. Key barriers to treatment described by HPs and PCPs included patients' substance use disorders, mental health, transportation availability, history of non-adherence, and concern about side effects. PCPs also focused on medication cost as a system-based barrier. The main facilitators of treatment initiation and adherence described by both HPs and PCPs were provider education and encouragement. HPs focused almost exclusively on provider-based facilitators, while PCPs noted patient-based facilitators including past adherence, media exposure to information about HCV medications, a desire to clear the virus, and positive feedback regarding treatment response. Providers generally focused on perceived patient-level barriers to HCV treatment initiation and adherence, as well as provider-level facilitators; PCPs additionally noted patient preferences and system-level issues that guide decision making regarding treatment initiation. While HPs focused almost exclusively on provider-level facilitators, PCPs additionally focused on patient-level facilitators of treatment. These data provide novel insights and suggest focusing on patient, provider, and system-level strategies to further improve HCV treatment initiation and adherence.

An Innovative Framework to Improve Teratogenic Medication Risk Counseling.

Health care providers in the Veterans Affairs system are caring for a growing number of women of childbearing age. Prior research shows that a significant number of women veterans are prescribed category D or X teratogenic medications. However, the majority do not receive teratogenic risk or contraceptive counseling. In order to improve teratogenic medication prescribing practices at the Veterans Affairs Pittsburgh Healthcare System, we developed a framework called TARCC to guide primary care providers through appropriate teratogenic risk counseling. The components of TARCC are teratogen (Are you prescribing a potential teratogen?), alternative (Did you consider a nonteratogenic alternative?), risks (Did you discuss the risks of the medication?), contraception (Did you discuss contraception?), and chart (Did you chart your discussion?). We incorporated TARCC into an electronic health record reminder. Additional probes, educational tools, and options to place consults and orders are included within the reminder. The Teratogen Pharmacy E-consult prompts a pharmacist to electronically review a patient's medications and provide recommendations regarding potential alternatives and discussions of risks and benefits. This article describes the development and implementation of the TARCC framework in a clinical reminder.

Left Ventral Stream White Matter Connectivity Predicts Response to Semantic Feature Analysis Treatment in Chronic Aphasia

Left Ventral Stream White Matter Connectivity Predicts Response to Semantic Feature Analysis Treatment in Chronic Aphasia