Latest news with #VeteransHealthAdministration
Medscape
14-07-2025
- Health
- Medscape
Environmentally Friendly Inhalers Fall Short on Patient Tolerance
Changing to a dry powder inhaler (DPI) was associated with more healthcare use by adult patients with asthma, based on data from approximately 260,000 individuals. The Veterans Health Administration adopted a formulary change in 2021 that switched from the standard budesonide-formoterol metered-dose therapy to fluticasone-salmeterol dry powder therapy, but differences in patient outcomes after the change have not been well-studied, wrote Alexander Rabin, MD, of the University of Michigan, Ann Arbor, Michigan, and colleagues. The change affected hundreds of thousands of veterans, and the researchers wanted to understand how this large-scale shift in prescribing affected clinical outcomes, Rabin said in an interview. The formulary change was driven by a contract renegotiation and cost considerations rather than environmental concerns, but there is great interest in understanding differences in clinical outcomes between metered-dose inhalers (MDIs) and DPIs because DPIs lack the aerosol propellants that may contribute to global warming, Rabin noted. 'The VA's [Veterans Affairs] policy shift created a natural experiment to study the clinical effects of switching from MDIs to DPIs on a broad scale,' he said. The researchers used data from the US VA healthcare system from January 2018 through December 2022 to design a matched observational cohort study and a within-person self-controlled case series (SCCS). They measured rescue medication use, emergency department visits, and hospitalizations before and after the formulary change. The study population for the SCCS included 260,268 patients with asthma who switched from the standard metered-dose therapy to dry powder therapy; the median age was 71 years, and 91% were men. Although the period of DPI use was associated with a 10% decrease in albuterol fills compared with periods of MDI use, it was associated with a 2% increase in prednisone fills, a 5% increase in all-cause emergency department visits, a 6% increase in respiratory-related emergency department visits, an 8% increase in all-cause hospitalizations, a 10% increase in respiratory-related hospitalizations, and a 24% increase in pneumonia-specific hospitalizations. The cohort study included 258,557 patients who switched to a DPI and matched patients who did not. The mean age in this group was 68.9 years; 94% were men. At 180 days after the switch, patients who switched to a DPI experienced increases in all-cause hospitalizations compared with those who didn't switch (16.14% vs 15.64%). Patients who switched also had more respiratory-related hospitalizations and pneumonia-related hospitalizations compared with the control group (3.15% vs 2.74% and 1.15% vs 1.03%, respectively). However, no differences in mortality were noted. The researchers had heard anecdotally from colleagues and patients that the DPI version of fluticasone-salmeterol might be less well tolerated than MDI budesonide-formoterol, Rabin told Medscape Medical News . 'Still, we were surprised to see evidence of worse outcomes, including increased emergency department visits and hospitalizations for COPD [chronic obstructive pulmonary disease] and asthma exacerbations,' he said. 'We had hoped the transition might be neutral or even beneficial because the fluticasone-salmeterol DPI is both less expensive and more climate-friendly than the budesonide-formoterol MDI, but the data showed there was an association with increased healthcare utilization after the switch,' he noted. Data Support Flexible Prescribing In light of the study findings, the researchers are working with the VA Pharmacy Benefits Management Services to review the formulary decision and consider more flexibility around prescribing budesonide-formoterol when clinically appropriate, Rabin said. 'This experience also highlights a broader opportunity: To improve how large systems implement medication or device changes,' he said. 'Transitions like these can create confusion or disruption for patients and clinicians alike, but better communication, training, and support could help ensure that changes are both clinically effective and patient-centered,' he said. 'We don't yet know whether the worse outcomes were due to differences in the medications themselves (fluticasone vs budesonide), the delivery devices (DPI vs MDI), or the way the switch was implemented,' Rabin told Medscape Medical News . The researchers are collecting qualitative data from veterans and providers to understand their experiences with the formulary change, he said. 'As the healthcare community looks to reduce the environmental impact of respiratory care, it is essential that we do so in ways that protect, and ideally improve, patient outcomes. Sustainable solutions must be safe, effective, and equitable for those we serve,' he added. Nonmedical switching of medications because of insurance coverage or other reasons not decided by clinicians is happening more frequently, said David M. Mannino III, MD, pulmonologist and professor at the University of Kentucky, Lexington, Kentucky, in an interview. The VA population tends to be sicker, poorer, and more complicated than the general medical population; therefore, the increased use of health resources was not unexpected, said Mannino. 'In general, it is a bit more difficult to use a DPI, so in many practices, sicker patients tend to be on MDIs or nebulizers,' he noted. 'Forcing patients to switch might cause complications if they are not able to properly use the device they were switched to,' he said. The current study looked at the data in different ways, and the findings for a higher risk for pneumonia and emergency department visits were consistently increased, although there was no increased risk for death, he said. 'These data are compelling,' Mannino told Medscape Medical News . 'I think the VA system that instituted these changes needs to take a close look at these data and consider whether other factors need to be included in future decision-making,' he said. The current study had limitations inherent in its design, such as a lack of data that any of the medication was taken vs prescribed, Mannino noted. Other options, such as nebulizers, could be used in some patients, and newer medications now available to treat COPD might be an adequate alternative to inhalers, he added.
Medscape
24-06-2025
- Health
- Medscape
Dementia Risk May Follow a Geographic Pattern
TOPLINE: Dementia incidence varied significantly by US region in a new study, with the Southeast showing a 25% higher risk and the Northwest and Rocky Mountains each showing a 23% higher risk compared to the Mid-Atlantic. Investigators said the findings highlight the need for a geographically tailored approach to address dementia risk factors and diagnostic services. METHODOLOGY: Researchers conducted a cohort study using data from the US Veterans Health Administration for more than 1.2 million older adults without dementia (mean age, 73.9 years; 98%% men) from 1999 to 2021. The average follow-up was 12.6 years. Ten geographical regions across the US were defined using the CDC National Center for Chronic Disease Prevention and Health Promotion definition. The diagnosis of dementia was made using International Classification of Diseases, Ninth and Tenth Revision codes from inpatient and outpatient visits. TAKEAWAY: Dementia incidence rates per 1000 person-years were lowest in the Mid-Atlantic (11.2; 95% CI, 11.1-11.4) and highest in the Southeast (14.0; 95% CI, 13.8-14.2). After adjusting for demographics, compared with the Mid-Atlantic region, dementia incidence was highest in the Southeast (rate ratio [RR], 1.25), followed by the Northwest and Rocky Mountains (RR for both, 1.23), South (RR, 1.18), Southwest (RR, 1.13), and Midwest and South Atlantic (RR for both, 1.12). The Great Lakes and Northeast regions had < a 10% difference in incidence. Results remained consistent after adjusting for rurality and cardiovascular comorbidities, and after accounting for competing risk for death. IN PRACTICE: 'This study provides valuable insights into the regional variation in dementia incidence among US veterans in that we observed more than 20% greater incidence in several regions compared with the Mid-Atlantic region,' the investigators wrote. 'By identifying areas with the highest incidence rates, resources can be better allocated and targeted interventions designed to mitigate the impact of dementia on vulnerable populations,' they added. SOURCE: This study was led by Christina S. Dintica, PhD, University of California, San Francisco. It was published online on June 9 in JAMA Neurology. LIMITATIONS: This study population was limited to US veterans, limiting the generalizability of the findings. Education level was defined using educational attainment rates in the participants' zip codes rather than individual data. Additionally, because residential history was limited to a single location per participant, migration patterns could not be tracked. DISCLOSURES: This study was supported by grants from the Alzheimer's Association, the National Institute on Aging, and the Department of Defense. One author reported serving on data and safety monitoring boards for studies sponsored by the National Institutes of Health, as well as holding advisory board membership and receiving personal fees from industry. Full details are listed in the original article. The other four investigators reported no relevant financial conflicts. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Medscape
23-06-2025
- Health
- Medscape
Giving Patients a Leg Up for Healthy Behavior Change
Our patients regularly encounter an abundance of addictive ultra-processed, hyper-palatable, energy dense foods, and many also lead very sedentary lives. Expecting patients to restrict food and start exercising simply because they've been advised to assumes they have a level of self-regulation few people possess and many did not develop early in life. Connecting patients with health and well-being coaching (HWC) can help them overcome barriers to change and give them a leg up as they work to adopt and sustain healthy habits. HWC fills a gap between traditional and lifestyle medicine by effectively promoting healthy behaviors to assist in the prevention or treatment of lifestyle-related disease, such as obesity, diabetes, hypertension, and pulmonary and vascular diseases. The need is great. According to the CDC, in 2020, 40% of US. adults had ≥ 2 chronic conditions, many of which can be effectively prevented and treated by lifestyle behaviors. Recognizing that unmet need, a consortium of three national coach credentialing organizations, four medical societies, and 72 healthcare organizations led by National Board for Health and Wellness Coaching (NBHWC) was formed in 2020 to advocate for the reimbursement of HWC services in the US healthcare system, as described in the American Journal of Lifestyle Medicine ( AJLM ) article Health and Wellness Coaching Services: Making the Case for Reimbursement. The Veterans Health Administration (VHA), which offers HWC services to veterans, also partnered in the initiative to establish Current Procedural Terminology (CPT) codes for HWC services. Lead co-authors of the AJLM paper, Moain Abu Dabrh, MB, BCh, MS, Mayo Clinic, Jacksonville, and Margaret Moore, MBA, McLean Hospital, Institute of Coaching, Belmont, Massachusetts, described 'our five-year path of evidence gathering, coalition building, and advocacy efforts.' They added, 'this coalition documented over 4 million delivered HWC sessions in making the case for reimbursement to CMS and the AMA.' These advocacy efforts contributed to the creation and implementation of Category III CPT codes that enable the tracking of and billing for HWC services , and the decision by the Centers for Medicare & Medicaid Services (CMS) to add the codes on a provisional basis to the Medicare Telehealth list starting in 2024. The codes are: 0591T, health and well-being coaching face-to-face; individual, initial assessment (at least 60 min); 0592T, health and well-being coaching; individual, follow-up session, at least 30 min; and 0593T, health and well-being Coaching group (two or more individuals), at least 30 min. What is Health and Wellness Coaching? HWC is a patient-centered approach that includes patient-determined goals and the use of self-discovery or active learning to work toward those goals. Behavior change is facilitated by self-monitoring techniques, patient accountability, and health education — all within the context of an interpersonal relationship with a trained coach. Professional health and well-being coaches are qualified by education, completion of certified training, national examination, and when applicable, licensure/regulation. The NBHWC established national HWC standards and certification in partnership with the National Board of Medical Examiners, as noted in the AJLM article. Certified training includes behavioral change theory, motivational strategies, communication techniques, and health education and promotion theories, which are used to assist patients to develop intrinsic motivation and obtain skills to create sustainable change for improved health and well-being. Coaching in Action Since the VHA implemented the HWC CPT codes in 2020, 73,351 unique veterans have had 322,655 sessions with an NBHWC-certified coach, said Kavitha Reddy, MD, associate director of employee whole health in the VHA Office of Patient-Centered Care and Cultural Transformation, St Louis. Within VHA, more than 300 NBHWC-certified whole health coaches are now in place across the enterprise. 'I frequently refer my patients to work with a coach,' Janet Clark, MD, physician lead of the VHA HWC program, told me. 'Our coaches are extremely effective with the veterans we serve, fostering sustainable engagement in healthy lifestyles and treatment plans, crucial for most chronic disease and symptom management.' Sara Noyes, NBHWC-certified HWC, leads the VHA HWC program with Clark and has written about the power of HWC. 'HWC can enhance the health and well-being of service members and veterans as they are better equipped and empowered to live lives to the fullest,' Noyes said. A study examining the VHA Whole Health Coaching program supports Noyes endorsement of HWC. Massachusetts General Hospital (MGH) contributed data to the AJLM article. Jacob Mirsky, MD, medical director of the Healthy Lifestyle Program at MGH, heads a team that includes four NBHWC-certified coaches who are paired with a physician or nurse practitioner for reimbursed patient visits. Their approach combines shared virtual lifestyle medicine appointments with virtual 1-on-1 HWC sessions. Mirsky has published multiple papers on lifestyle medicine using HWC sessions, demonstrating improved self-reported health behaviors and positive chronic disease outcomes. 'The coaches and their relational, goal-striving style are key to patient success," said Mirsky, who is also an assistant professor of medicine at Harvard Medical School, Boston, Massachusetts. Challenges Remain The temporary approval of HWC CPT codes has been extended through 2029. Currently, payment for HWC services is challenging; however, the AJLM article outlined five emerging paths to reimbursement: Direct patient billing: Medical practices can bill patients directly for HWC services. Value-based care funding: When medical practices receive monthly value-based payments for patient care, some of the funds could be allocated to HWC services. CPT codes: Medical practices can use certain CPT codes to bill services provided by qualified HWC working under physician supervision. These include chronic-care management codes for Medicare beneficiaries and preventive medicine counseling codes for non-Medicare patients. Negotiated reimbursement: Medical practices could negotiate with payers to secure reimbursement for the telehealth HWC CPT codes Health savings and flexible spending accounts: Health and wellness services may qualify for reimbursement under these accounts when prescribed by a physician. Federal rules require that the services be part of medically necessary treatment. Medical practices should look into whether any of the existing reimbursement pathways can work for their practices and with their patients. Advocates continue to work on formal HWC reimbursement pathways, including urging CMS to integrate HWC CPT codes into Medicare's chronic care management program as permanent G codes. Their efforts emphasize that broad access to HWC services would help realize the government's goal to Make America Healthy Again and the vision of CMS Administrator Mehmet Oz, MD. The hope is patients needing HWC will have access to it and providers are reimbursed for these invaluable services. The evolution of HWC along with lifestyle medicine presents 'a transformative shift in healthcare, ' the AJLM article noted. HWC is a long-awaited bridge between recommending healthy behavior change to patients and patients actually making those changes, thus improving their health. All qualifying patients should have access to HWC with physician oversight and referral. Mirsky is owner of Lifestyle Medicine Consulting LLC. Moore is CEO of Wellcoaches Corp.
Medscape
11-06-2025
- Health
- Medscape
Race, Ethnicity Linked to Divergent Outcomes in AF
In a cohort of 157,332 in the Veterans Health Administration with atrial fibrillation (AF), Black patients had a 14% higher risk for stroke than White patients, but Black, Asian, and Hispanic patients were less likely than White patients to die from stroke. METHODOLOGY: Researchers identified 157,332 patients in the Veterans Health Administration with incident AF (mean age, 72.9 ± 10.5 years, 97.8% men) from January 1, 2014, to December 31, 2021, with follow-up through May 31, 2022. The study's independent variables were race and ethnicity. The primary outcomes were the incidence of stroke and mortality from any cause. Cox proportional hazard models were used to assess associations between race and ethnicity and patient outcomes. TAKEAWAY: Overall, 22,628 patients (14.7%) experienced a stroke (46.3 per 1,000 person-years) during the study period, with Black patients showing a higher risk for the event (adjusted hazard ratio [AHR], 1.14; 95% CI, 1.09-1.20) than White patients. No significant differences were observed between White patients and American Indian/Alaska Native, Asian, or Hispanic patients. Overall, 52,288 patients (33.2%) died (96.1 per 1,000 person-years), with Asian (AHR, 0.85; 95% CI, 0.78-0.93), Black (AHR, 0.92; 95% CI, 0.89-0.95), and Hispanic (AHR, 0.82; 95% CI, 0.77-0.87) patients showing a lower risk for death than White patients. Among patients with stroke, mortality rates were higher for racial and ethnic minoritized groups, while those without stroke showed lower mortality rates for Asian, Black, and Hispanic patients compared to White patients. IN PRACTICE: 'Our findings of higher rates of stroke in Black patients, even when controlling for anticoagulant use, suggest that there are other mechanisms by which stroke prevention must be addressed in ongoing VA quality improvement efforts for AF. These include improving equitable access to all AF treatment strategies beyond anticoagulation, including rhythm control agents and therapeutic procedures such as cardiac ablation, for which notable disparities have been observed,' the researchers reported. 'Furthermore, our observation that the magnitude of the association between race and stroke decreased with the addition of socioeconomic markers in our stepwise modeling suggests that addressing social factors and structural determinants beyond the health system may improve downstream AF outcomes.' SOURCE: The study was led by Utibe R. Essien, MD, MPH, of the David Geffen School of Medicine at the University of California, Los Angeles, and Leslie R.M. Hausmann, PhD, MS, of the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System, Pittsburgh. It was published online in JACC: Advances . LIMITATIONS: The study primarily included men receiving care within the Veterans Health Administration, limiting crossover to non-VA settings or practices with larger proportions of female patients. Stroke outcomes were identified solely through VA data. The analysis lacked data on specific cause of death, preventing an analysis of cardiovascular mortality. DISCLOSURES: The study received funding from the Veterans Affairs Health Services Research and Development Division and the American Heart Association Amos Medical Faculty Development Program Award. The funders had no role in the study design, data collection, and analysis. The authors reported having no relationships relevant to the paper's contents.
Gizmodo
09-06-2025
- Health
- Gizmodo
These U.S. States Have the Highest Rates of Dementia
Your zip code may shape your aging brain's health. New research out today shows that people's odds of being diagnosed with dementia differ significantly across different parts of the U.S. Scientists at the University of California, San Francisco, led the study, published Monday in JAMA Neurology. They analyzed the medical records of veterans, finding that dementia rates were noticeably higher in the Southeast, Northwest, and other regions, even after accounting for some possible factors like income. The findings suggest that deep-seated regional differences can contribute to dementia risk, the researchers say. Dementia is a growing public health issue, particularly among the elderly. More than 6 million Americans are living with dementia currently and a government-funded study this February projected that 42% of Americans over 55 will develop it in their lifetime. It's a complex condition, with most cases caused by a mix of environmental and/or genetic factors. But according to senior study author and neurologist Kristine Yaffe, there's been little research looking at how the risk of dementia can vary geographically, at least on a national level. Yaffe and her team had access to a dataset that had the potential to shed light on that: deidentified records from people enrolled in the Veterans Health Administration, the largest integrated healthcare system in the U.S. 'We realized the VA national data would allow for such an investigation as the VA has a uniform way of capturing data across the U.S.,' Yaffe, who is also chief of neuropsychiatry at the San Francisco VA healthcare system, told Gizmodo in an email. 'There are no other national healthcare systems that have this.' Yaffe's team studied the health of more than 1.2 million randomly selected VA patients 65 years and older who had no pre-existing dementia. These people were followed for an average length of 12 years. After adjusting for age, dementia rates were lowest in the Mid-Atlantic region, covering states like Pennsylvania, Maryland, and Virginia. Using this as a baseline, the researchers found that dementia rates were 25% higher in the Southeast (Kentucky, Tennessee, and Alabama); 23% higher in both the Northwest (Idaho, Oregon, and Washington) and the Rocky Mountains (Colorado, Montana, and the Dakotas); 18% higher in the South (Texas, New Mexico, and Louisiana); 13% higher in the Southwest (California, Nevada, and Arizona); and 7% in the Northeast (New York). 'This is a very large difference, especially given that these are all veterans with care at the VAHS,' Yaffe said. 'It was really surprising we saw such big differences.' The researchers reasoned that factors such as a person's average level of education, how rural a state was, or the rate of other health conditions like heart disease within these states might explain most of the variance they found. But even when they adjusted for these variables, the patterns barely budged at all. That could mean there are other reasons—reasons not so easily captured through medical records alone—why someone in New Jersey will tend to have a lower risk of dementia than a similar person in Kentucky. 'It's possible that the differences are explained by lifelong differences in things like education quality (vs quantity) and social determinants of health might be driving some of the differences,' Yaffe said. The findings now leave open more questions to be answered, which the team plans to start digging into. With any luck, the lessons they learn might help us find new ways to better prevent dementia.
