Article

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (< 1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, > 35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥ 5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (> 5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (< 1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, > 35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥ 5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (> 5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Infantile hemangioma (IH) is the most common vascular tumor of infancy, appearing within the first few weeks of life and typically reaching peak size by age 3 to 5 months.¹ It classically manifests as a raised or flat bright-red lesion in the upper dermis of the skin and/or subcutaneous tissue and can vary in number, size, shape, and location.² It is characterized by a rapid proliferative phase, especially between 5 and 8 weeks of age, followed by gradual spontaneous regression over 1 to 10 years.^1-3

Infantile hemangiomas are categorized based on depth (superficial, deep, or mixed) and distribution pattern (focal, multifocal, segmental, or indeterminate).⁴ In most cases, complete regression occurs by age 4 years, but there can be residual telangiectasia, fibrofatty tissue, and/or scarring.^1,4 About 10% to 15% of IHs result in complications that require medical intervention (eg, visual, airway, or auditory compromise; ulceration; disfigurement); ideally, these patients should be referred to a specialist by 5 weeks of age.⁴ Prompt assessment of IH severity is essential to prevent or mitigate potential complications and ultimately improve outcomes.³ Social drivers of health contribute to delayed diagnosis and management of hemangiomas, leading to increased complications in some patient populations.^5-7

Epidemiology

Infantile hemangiomas are estimated to manifest in 4.5% of infants in the United States.¹ The most common type is superficial IH, typically found on the head or neck.⁵ Risk factors in infants include female sex, White race, premature birth, and low birth weight (< 1000 g).^1,3 Maternal risk factors include advanced gestational age (ie, > 35 years), multiple gestations, family history of IH, tobacco use, use of progesterone therapy during pregnancy, and pre-eclampsia.^1,3

Focal IH typically manifests as a single localized lesion that can occur anywhere on the body.^2,3 In contrast, segmental IH manifests in a linear pattern and/or is distributed on a large anatomic area, most commonly on the face and less frequently the extremities and trunk.^2,3 Segmental IHs are more common in Hispanic patients and carry a higher risk for morbidity, often complicated by ulceration that can lead to functional and cosmetic challenges.⁸

Key Clinical Features

Superficial IH in patients with darker skin tones may appear as a dark-red or violaceous papule or plaque compared to bright red in lighter skin tones.⁵ Deep IH may appear as a soft, round, flesh-colored or blue-hued subcutaneous mass, the color of which may be harder to appreciate in those with darker skin tones.⁵

Worth Noting

Complications from IH may require imaging, close follow-up, systemic therapy, multidisciplinary care, and advanced health literacy and patient/family navigation. Multifocal IHs (≥ 5 lesions) are more likely to be associated with infantile hepatic hemangiomas.^2,3 Large (> 5 cm) segmental IHs on the face and lumbosacral area require further evaluation for PHACES (posterior fossa malformation, hemangiomas, arterial anomalies, cardiac defects, eye anomalies, and sternal raphe/cleft defects) and LUMBAR (lower-body segmental IH; urogenital anomalies and ulceration; ­myelopathy; bony deformities; anorectal malformations and arterial anomalies; and renal anomalies) syndromes, which are more common in patients of Hispanic ethnicity.^2,3

The Infantile Hemangioma Referral Score is a recently validated tool that can assist primary care physicians in timely referral of IHs requiring early specialist intervention.^4,9 It takes into account the location, number, and size of the lesions and the age of the patient; these factors help to determine which IHs may be managed conservatively vs those that may require treatment to prevent ­life-threatening complications.^1-3 

Systemic corticosteroids historically have been the primary treatment for IH; however, in the past decade, propranolol oral solution (4.28 mg/mL) has become the first-line therapy for most infants requiring systemic management.¹⁰ It is the only medication approved by the US Food and Drug Administration for proliferating IH, with treatment initiation as young as 5 weeks corrected age.¹¹ As a nonselective beta-blocker, propranolol is believed to reduce IHs through vasoconstriction or by inhibition of angiogenesis.^1,4,10 

For small superficial IHs, treatment options include timolol maleate ophthalmic solution 0.5% (one drop applied twice daily to the IH) or pulsed dye laser therapy.^4,10 Surgical excision typically is avoided during infancy due to concerns about anesthetic risks and potential blood loss.^4,10 Surgery is reserved for cases involving residual fibrofatty tissue, postinvolution scarring, obstruction of vital structures, or lesions in aesthetically sensitive areas as well as when propranolol is contraindicated.^4,10

Health Disparity Highlight

Infants with skin of color and those of lower socioeconomic status (SES) face a heightened risk for delayed diagnosis and more advanced disease at the initial evaluation for IH.^5,7 Access barriers such as geographic limitations to specialty services, lack of insurance, underinsurance, and language differences impact timely diagnosis and treatment.^5,6 Implementation of telemedicine services in areas with limited access to specialists can facilitate early evaluation and risk stratification for IH.¹²

A retrospective cohort study of 804 children seen at a large academic hospital found that those of lower SES were more likely to seek care after 3 months of age than their higher-SES counterparts.⁶ Those who presented after 6 months of age also had higher IH severity scores compared to their counterparts with higher SES.⁶ Delayed access to care may cause children to miss the critical treatment window during the rapid proliferative growth phase.^6,12 However, children insured through Medicaid or the Children’s Health Insurance Program who participated in institutional care management programs (which assist in scheduling specialty care appointments within the institution) sought treatment earlier regardless of their SES, suggesting that such programs may help reduce disparities in timely access for children of lower SES.⁶ 

An epidemiologic study analyzing the demographics of children hospitalized across the United States demonstrated that Black infants with IH were more likely to belong to the lowest income quartile compared with White infants or those of other races. They also were 2 times older on average at initial presentation (1.8 vs 1.0 years), experienced longer hospitalizations (16.4 vs 13.8 days), and underwent more IH-related procedures than White infants and infants of other races (2.4, 1.9, and 2.1, respectively).⁷

These and other factors may contribute to missed windows of opportunity for timely treatment of high-risk IHs in patients with darker skin tones and/or those facing challenges stemming from social drivers of health.

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Systemic glucocorticoids play an important role in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations. They are recommended to shorten recovery time and increase forced expiratory volume in 1 second (FEV1) during exacerbations.¹ However, the role of the chronic use of inhaled corticosteroids (ICSs) in the treatment of COPD is less clear.

When added to inhaled β-2 agonists and muscarinic antagonists, ICSs can decrease the risk of exacerbations.¹ However, not all patients with COPD benefit from ICS therapy. The degree of benefit an ICS can provide has been shown to correlate with eosinophil count—a marker of inflammation. The expected benefit of using an ICS increases as the eosinophil count increases.¹ Maximum benefit can be observed with eosinophil counts ≥ 300 cells/µL, and minimal benefit is observed with eosinophil counts < 100 cells/µL. Adverse effects (AEs) of ICSs include a hoarse voice, oral candidiasis, and an increased risk of pneumonia.¹ Given the risk of AEs, it is important to limit ICS use in patients who are unlikely to reap any benefits.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest the use of ICSs in patients who experience exacerbations while using long-acting β agonist (LABA) plus long-acting muscarinic antagonist (LAMA) therapy and have an eosinophil count ≥ 100 cells/µL. Switching from LABA or LAMA monotherapy to triple therapy with LAMA/LABA/ICS may be considered if patients have continued exacerbations and an eosinophil count ≥ 300 cells/µL. De-escalation of ICS therapy should be considered if patients do not meet these criteria or if patients experience ICS AEs, such as pneumonia. The patients most likely to have increased exacerbations or decreased FEV1 with ICS withdrawal are those with eosinophil counts ≥ 300 cells/µL.^1,2

Several studies have explored the effects of ICS de-escalation in real-world clinical settings. A systematic review of 11 studies indicated that de-escalation of ICS in COPD does not result in increased exacerbations.³ A prospective study by Rossi et al found that in a 6-month period, 141 of 482 patients on ICS therapy (29%) had an exacerbation. In the opposing arm of the study, 88 of 334 patients (26%) with deprescribed ICS experienced an exacerbation. The difference between these 2 groups was not statistically significant.⁴ The researchers concluded that in real-world practice, ICS withdrawal can be safe in patients at low risk of exacerbation.

About 25% of veterans (1.25 million) have been diagnosed with COPD.⁵ To address this, the US Department of Veterans Affairs (VA) and US Department of Defense published updated COPD guidelines in 2021 that specify criteria for de-escalation of ICS.⁶ Guidelines, however, may not be reflected in common clinical practice for several years following publication. The VA Academic Detailing Service (ADS) provides tools to help clinicians identify patients who may benefit from changes in treatment plans. A recent ADS focus was the implementation of a COPD dashboard, which identifies patients with COPD who are candidates for ICS de-escalation based on comorbid diagnoses, exacerbation history, and eosinophil count. VA pharmacists have an expanded role in the management of primary care disease states and are therefore well-positioned to increase adherence to guideline-directed therapy. The objective of this quality improvement project was to determine the impact of pharmacist-driven de-escalation on ICS usage in veterans with COPD.

Methods

This project was conducted in an outpatient clinic at the Robley Rex VA Medical Center beginning September 21, 2023, with a progress note in the Computerized Patient Record System (CPRS). Eligible patients were selected using the COPD Dashboard provided by ADS. The COPD Dashboard defined patients with COPD as those with ≥ 2 outpatient COPD diagnoses in the past 2 years, 1 inpatient discharge COPD diagnosis in the past year, or COPD listed as an active problem. COPD diagnoses were identified using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes (Appendix).

Candidates identified for ICS de-escalation by the dashboard were excluded if they had a history of COPD exacerbation in the previous 2 years. The dashboard identified COPD exacerbations via ICD-10 codes for COPD or acute respiratory failure for inpatient discharges, emergency department (ED) visits, urgent care visits, and community care consults with 1 of the following terms: emergency, inpatient, hospital, urgent, ED (self). The COPD dashboard excluded patients with a diagnosis of asthma.

After patients were selected, they were screened for additional exclusion criteria. Patients were excluded if a pulmonary care practitioner managed their COPD; if identified via an active pulmonary consult in CPRS; if a non-VA clinician prescribed their ICS; or if they were being treated with roflumilast, theophylline, or chronic azithromycin. Individuals taking these 3 drugs were excluded due to potential severe and/or refractory COPD. Patients also were excluded if they: (1) had prior ICS de-escalation failure (defined as a COPD exacerbation following ICS de-escalation that resulted in ICS resumption); (2) had a COPD exacerbation requiring systemic corticosteroids or antibiotics in the previous year; (3) had active lung cancer; (4) did not have any eosinophil levels in CPRS within the previous 2 years; or (5) had any eosinophil levels ≥ 300 cells/µL in the previous year.

Each patient who met the inclusion criteria and was not excluded received a focused medication review by a pharmacist who created a templated progress note, with patient-specific recommendations, that was entered in the CPRS (eAppendix). The recommendations were also attached as an addendum to the patient’s last primary care visit note, and the primary care practitioner (PCP) was alerted via CPRS to consider ICS de-escalation and non-ICS alternatives. Tapering of ICS therapy was offered as an option to de-escalate if abrupt discontinuation was deemed inappropriate. PCPs were also prompted to consider referral to a primary care clinical pharmacy specialist for management and follow-up of ICS de-escalation.

The primary outcome was the number of patients with de-escalated ICS at 3 and 6 months following the recommendation. Secondary outcomes included the number of: patients who were no longer prescribed an ICS or who had a non-ICS alternative initiated at a pharmacist’s recommendation; patients who were referred to a primary care clinical pharmacy specialist for ICS de-escalation; COPD exacerbations requiring systemic steroids or antibiotics, or requiring an ED visit, inpatient admission, or urgent-care clinic visit; and cases of pneumonia or oral candidiasis. Primary and secondary outcomes were evaluated via chart review in CPRS. For secondary outcomes of pneumonia and COPD exacerbation, identification was made by documented diagnosis in CPRS. For continuous data such as age, the mean was calculated.

Results

Pharmacist ICS de-escalation recommendations were made between September 21, 2023, and November 19, 2023, for 106 patients. The mean age was 72 years and 99 (93%) patients were male (Table 1). Forty-one (39%) of the patients used tobacco at the time of the study. FEV1 was available for 69 patients with a mean of 63% (GOLD grade 2).¹ Based on FEV1 values, 16 patients had mild COPD (GOLD grade 1), 37 patients had moderate COPD (GOLD grade 2), 14 patients had severe COPD (GOLD grade 3), and 2 patients had very severe COPD (GOLD grade 4).¹ Thirty-four patients received LABA + LAMA + ICS, 65 received LABA + ICS, 2 received LAMA + ICS, and 5 received ICS monotherapy. The most common dose of ICS was a moderate dose (Table 2). Only 2 patients had an ICS AE in the previous year.

ICS de-escalation recommendations resulted in ICS de-escalation in 50 (47.2%) and 62 (58.5%) patients at 3 and 6 months, respectively. The 6-month ICS de-escalation rate by ICS dose at baseline was 72.2% (high dose), 60.0% (moderate), and 30.8% (low). De-escalation at 6 months by GOLD grade at baseline was 56.3% (9 of 16 patients, GOLD 1), 64.9% (24 of 37 patients, GOLD 2), 50% (7 of 14 patients, GOLD 3), and 50% (1 of 2 patients, GOLD 4). Six months after the ICS de-escalation recommendation appeared in the CPRS, the percentage of patients on LABA + ICS therapy dropped from 65 patients (61.3%) at baseline to 25 patients (23.6%).

Secondary outcomes were assessed at 3 and 6 months following the recommendation. Most patients with de-escalated ICS had their ICS discontinued and a non-ICS alternative initiated per pharmacist recommendations. At 6 months, 39 patients (36.8%) patients were referred to a patient aligned care team (PACT) pharmacist for de-escalation. Of the 39 patients referred to pharmacists, 69.2% (27 patients) were de-escalated; this compared to 52.2% (35 patients) who were not referred to pharmacists (Table 3).

ICS use increases the risk of pneumonia.¹ At 6 months, 11 patients were diagnosed with pneumonia; 3 patients were diagnosed with pneumonia twice, resulting in a total of 14 cases. Ten cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation. One patient had a documented case of oral candidiasis that occurred while on ICS therapy; no patients with discontinued ICS were diagnosed with oral candidiasis. In addition, 10 patients had COPD exacerbations; however no patients had exacerbations both before and after de-escalation. Six patients were on ICS therapy when they experienced an exacerbation, and 4 patients had an exacerbation after ICS de-escalation.

Discussion

More than half of patients receiving the pharmacist intervention achieved the primary outcome of ICS de-escalation at 6 months. Furthermore, a larger percentage of patients referred to pharmacists for the management of ICS de-escalation successfully achieved de-escalation compared to those who were not referred. These outcomes reflect the important role pharmacists can play in identifying appropriate candidates for ICS de-escalation and assisting in the management of ICS de-escalation. Patients referred to pharmacists also received other services such as smoking cessation pharmacotherapy and counseling on inhaler technique and adherence. These interventions can support improved COPD clinical outcomes.

The purpose of de-escalating ICS therapy is to reduce the risk of AEs such as pneumonia and oral candidiasis.¹ The secondary outcomes of this study support previous evidence that patients who have de-escalated ICS therapy may have reduced risk of AEs compared to those who remain on ICS therapy.³ Specifically, of the 14 cases of pneumonia that occurred during the study, 10 cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation.

ICS de-escalation may increase risk of increased COPD exacerbations.¹ However, the secondary outcomes of this study do not indicate that those with de-escalated ICS had more COPD exacerbations compared to those who continued on ICS. Pharmacists’ recommendations were more effective for patients with less severe COPD based on baseline FEV1.

The previous GOLD Guidelines for COPD suggested LABA + ICS therapy as an option for patients with a high symptom and exacerbation burden (previously known as GOLD Group D). Guidelines no longer recommend LABA + ICS therapy due to the superiority of triple inhaled therapy for exacerbations and the superiority of LAMA + LABA therapy for dyspnea.⁷ A majority of identified patients in this project were on LABA + ICS therapy alone at baseline. The ICS de-escalation recommendation resulted in a 61.5% reduction in patients on LABA + ICS therapy at 6 months. By decreasing the number of patients on LABA + ICS without LAMA, recommendations increased the number of patients on guideline-directed therapy.

Limitations

This study lacked a control group, and the rate of ICS de-escalation in patients who did not receive a pharmacist recommendation was not assessed. Therefore, it could not be determined whether the pharmacist recommendation is more effective than no recommendation. Another limitation was our inability to access records from non-VA health care facilities. This may have resulted in missed COPD exacerbations, pneumonia, and oral candidiasis prior to or following the pharmacist recommendation.

In addition, the method used to notify PCPs of the pharmacist recommendation was a CPRS alert. Clinicians often receive multiple daily alerts and may not always pay close attention to them due to alert fatigue. Early in the study, some PCPs were unknowingly omitted from the alert of the pharmacist recommendation for 10 patients due to human error. For 8 of these 10 patients, the PCP was notified of the recommendations during the 3-month follow-up period. However, 2 patients had COPD exacerbations during the 3-month follow-up period. In these cases, the PCP was not alerted to de-escalate ICS. The data for these patients were collected at 3 and 6 months in the same manner as all other patients. Also, 7 of 35 patients who were referred to a pharmacist for ICS de-escalation did not have a scheduled appointment. These patients were considered to be lost to follow-up and this may have resulted in an underestimation of the ability of pharmacists to successfully de-escalate ICS in patients with COPD.

Other studies have evaluated the efficacy of a pharmacy-driven ICS de-escalation.^8,9 Hegland et al reported ICS de-escalation for 22% of 141 eligible ambulatory patients with COPD on triple inhaled therapy following pharmacist appointments.⁸ A study by Hahn et al resulted in 63.8% of 58 patients with COPD being maintained off ICS following a pharmacist de-escalation initiative.⁹ However, these studies relied upon more time-consuming de-escalation interventions, including at least 1 phone, video, or in-person patient visit.^8,9

This project used a single chart review and templated progress note to recommend ICS de-escalation and achieved similar or improved de-escalation rates compared to previous studies.^8,9 Previous studies were conducted prior to the updated 2023 GOLD guidelines for COPD which no longer recommend LABA + ICS therapy. This project addressed ICS de-escalation in patients on LABA + ICS therapy in addition to those on triple inhaled therapy. Additionally, previous studies did not address rates of moderate to severe COPD exacerbation and adverse events to ICS following the pharmacist intervention.^8,9

This study included COPD exacerbations and cases of pneumonia or oral candidiasis as secondary outcomes to assess the safety and efficacy of the ICS de-escalation. It appeared there were similar or lower rates of COPD exacerbations, pneumonia, and oral candidiasis in those with de-escalated ICS therapy in this study. However, these secondary outcomes are exploratory and would need to be confirmed by larger studies powered to address these outcomes.

CONCLUSIONS

Pharmacist-driven ICS de-escalation may be an effective method for reducing ICS usage in veterans as seen in this study. Additional controlled studies are required to evaluate the efficacy and safety of pharmacist-driven ICS de-escalation.

Systemic glucocorticoids play an important role in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations. They are recommended to shorten recovery time and increase forced expiratory volume in 1 second (FEV1) during exacerbations.¹ However, the role of the chronic use of inhaled corticosteroids (ICSs) in the treatment of COPD is less clear.

When added to inhaled β-2 agonists and muscarinic antagonists, ICSs can decrease the risk of exacerbations.¹ However, not all patients with COPD benefit from ICS therapy. The degree of benefit an ICS can provide has been shown to correlate with eosinophil count—a marker of inflammation. The expected benefit of using an ICS increases as the eosinophil count increases.¹ Maximum benefit can be observed with eosinophil counts ≥ 300 cells/µL, and minimal benefit is observed with eosinophil counts < 100 cells/µL. Adverse effects (AEs) of ICSs include a hoarse voice, oral candidiasis, and an increased risk of pneumonia.¹ Given the risk of AEs, it is important to limit ICS use in patients who are unlikely to reap any benefits.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest the use of ICSs in patients who experience exacerbations while using long-acting β agonist (LABA) plus long-acting muscarinic antagonist (LAMA) therapy and have an eosinophil count ≥ 100 cells/µL. Switching from LABA or LAMA monotherapy to triple therapy with LAMA/LABA/ICS may be considered if patients have continued exacerbations and an eosinophil count ≥ 300 cells/µL. De-escalation of ICS therapy should be considered if patients do not meet these criteria or if patients experience ICS AEs, such as pneumonia. The patients most likely to have increased exacerbations or decreased FEV1 with ICS withdrawal are those with eosinophil counts ≥ 300 cells/µL.^1,2

Several studies have explored the effects of ICS de-escalation in real-world clinical settings. A systematic review of 11 studies indicated that de-escalation of ICS in COPD does not result in increased exacerbations.³ A prospective study by Rossi et al found that in a 6-month period, 141 of 482 patients on ICS therapy (29%) had an exacerbation. In the opposing arm of the study, 88 of 334 patients (26%) with deprescribed ICS experienced an exacerbation. The difference between these 2 groups was not statistically significant.⁴ The researchers concluded that in real-world practice, ICS withdrawal can be safe in patients at low risk of exacerbation.

About 25% of veterans (1.25 million) have been diagnosed with COPD.⁵ To address this, the US Department of Veterans Affairs (VA) and US Department of Defense published updated COPD guidelines in 2021 that specify criteria for de-escalation of ICS.⁶ Guidelines, however, may not be reflected in common clinical practice for several years following publication. The VA Academic Detailing Service (ADS) provides tools to help clinicians identify patients who may benefit from changes in treatment plans. A recent ADS focus was the implementation of a COPD dashboard, which identifies patients with COPD who are candidates for ICS de-escalation based on comorbid diagnoses, exacerbation history, and eosinophil count. VA pharmacists have an expanded role in the management of primary care disease states and are therefore well-positioned to increase adherence to guideline-directed therapy. The objective of this quality improvement project was to determine the impact of pharmacist-driven de-escalation on ICS usage in veterans with COPD.

Methods

This project was conducted in an outpatient clinic at the Robley Rex VA Medical Center beginning September 21, 2023, with a progress note in the Computerized Patient Record System (CPRS). Eligible patients were selected using the COPD Dashboard provided by ADS. The COPD Dashboard defined patients with COPD as those with ≥ 2 outpatient COPD diagnoses in the past 2 years, 1 inpatient discharge COPD diagnosis in the past year, or COPD listed as an active problem. COPD diagnoses were identified using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes (Appendix).

Candidates identified for ICS de-escalation by the dashboard were excluded if they had a history of COPD exacerbation in the previous 2 years. The dashboard identified COPD exacerbations via ICD-10 codes for COPD or acute respiratory failure for inpatient discharges, emergency department (ED) visits, urgent care visits, and community care consults with 1 of the following terms: emergency, inpatient, hospital, urgent, ED (self). The COPD dashboard excluded patients with a diagnosis of asthma.

After patients were selected, they were screened for additional exclusion criteria. Patients were excluded if a pulmonary care practitioner managed their COPD; if identified via an active pulmonary consult in CPRS; if a non-VA clinician prescribed their ICS; or if they were being treated with roflumilast, theophylline, or chronic azithromycin. Individuals taking these 3 drugs were excluded due to potential severe and/or refractory COPD. Patients also were excluded if they: (1) had prior ICS de-escalation failure (defined as a COPD exacerbation following ICS de-escalation that resulted in ICS resumption); (2) had a COPD exacerbation requiring systemic corticosteroids or antibiotics in the previous year; (3) had active lung cancer; (4) did not have any eosinophil levels in CPRS within the previous 2 years; or (5) had any eosinophil levels ≥ 300 cells/µL in the previous year.

Each patient who met the inclusion criteria and was not excluded received a focused medication review by a pharmacist who created a templated progress note, with patient-specific recommendations, that was entered in the CPRS (eAppendix). The recommendations were also attached as an addendum to the patient’s last primary care visit note, and the primary care practitioner (PCP) was alerted via CPRS to consider ICS de-escalation and non-ICS alternatives. Tapering of ICS therapy was offered as an option to de-escalate if abrupt discontinuation was deemed inappropriate. PCPs were also prompted to consider referral to a primary care clinical pharmacy specialist for management and follow-up of ICS de-escalation.

The primary outcome was the number of patients with de-escalated ICS at 3 and 6 months following the recommendation. Secondary outcomes included the number of: patients who were no longer prescribed an ICS or who had a non-ICS alternative initiated at a pharmacist’s recommendation; patients who were referred to a primary care clinical pharmacy specialist for ICS de-escalation; COPD exacerbations requiring systemic steroids or antibiotics, or requiring an ED visit, inpatient admission, or urgent-care clinic visit; and cases of pneumonia or oral candidiasis. Primary and secondary outcomes were evaluated via chart review in CPRS. For secondary outcomes of pneumonia and COPD exacerbation, identification was made by documented diagnosis in CPRS. For continuous data such as age, the mean was calculated.

Results

Pharmacist ICS de-escalation recommendations were made between September 21, 2023, and November 19, 2023, for 106 patients. The mean age was 72 years and 99 (93%) patients were male (Table 1). Forty-one (39%) of the patients used tobacco at the time of the study. FEV1 was available for 69 patients with a mean of 63% (GOLD grade 2).¹ Based on FEV1 values, 16 patients had mild COPD (GOLD grade 1), 37 patients had moderate COPD (GOLD grade 2), 14 patients had severe COPD (GOLD grade 3), and 2 patients had very severe COPD (GOLD grade 4).¹ Thirty-four patients received LABA + LAMA + ICS, 65 received LABA + ICS, 2 received LAMA + ICS, and 5 received ICS monotherapy. The most common dose of ICS was a moderate dose (Table 2). Only 2 patients had an ICS AE in the previous year.

ICS de-escalation recommendations resulted in ICS de-escalation in 50 (47.2%) and 62 (58.5%) patients at 3 and 6 months, respectively. The 6-month ICS de-escalation rate by ICS dose at baseline was 72.2% (high dose), 60.0% (moderate), and 30.8% (low). De-escalation at 6 months by GOLD grade at baseline was 56.3% (9 of 16 patients, GOLD 1), 64.9% (24 of 37 patients, GOLD 2), 50% (7 of 14 patients, GOLD 3), and 50% (1 of 2 patients, GOLD 4). Six months after the ICS de-escalation recommendation appeared in the CPRS, the percentage of patients on LABA + ICS therapy dropped from 65 patients (61.3%) at baseline to 25 patients (23.6%).

Secondary outcomes were assessed at 3 and 6 months following the recommendation. Most patients with de-escalated ICS had their ICS discontinued and a non-ICS alternative initiated per pharmacist recommendations. At 6 months, 39 patients (36.8%) patients were referred to a patient aligned care team (PACT) pharmacist for de-escalation. Of the 39 patients referred to pharmacists, 69.2% (27 patients) were de-escalated; this compared to 52.2% (35 patients) who were not referred to pharmacists (Table 3).

ICS use increases the risk of pneumonia.¹ At 6 months, 11 patients were diagnosed with pneumonia; 3 patients were diagnosed with pneumonia twice, resulting in a total of 14 cases. Ten cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation. One patient had a documented case of oral candidiasis that occurred while on ICS therapy; no patients with discontinued ICS were diagnosed with oral candidiasis. In addition, 10 patients had COPD exacerbations; however no patients had exacerbations both before and after de-escalation. Six patients were on ICS therapy when they experienced an exacerbation, and 4 patients had an exacerbation after ICS de-escalation.

Discussion

More than half of patients receiving the pharmacist intervention achieved the primary outcome of ICS de-escalation at 6 months. Furthermore, a larger percentage of patients referred to pharmacists for the management of ICS de-escalation successfully achieved de-escalation compared to those who were not referred. These outcomes reflect the important role pharmacists can play in identifying appropriate candidates for ICS de-escalation and assisting in the management of ICS de-escalation. Patients referred to pharmacists also received other services such as smoking cessation pharmacotherapy and counseling on inhaler technique and adherence. These interventions can support improved COPD clinical outcomes.

The purpose of de-escalating ICS therapy is to reduce the risk of AEs such as pneumonia and oral candidiasis.¹ The secondary outcomes of this study support previous evidence that patients who have de-escalated ICS therapy may have reduced risk of AEs compared to those who remain on ICS therapy.³ Specifically, of the 14 cases of pneumonia that occurred during the study, 10 cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation.

ICS de-escalation may increase risk of increased COPD exacerbations.¹ However, the secondary outcomes of this study do not indicate that those with de-escalated ICS had more COPD exacerbations compared to those who continued on ICS. Pharmacists’ recommendations were more effective for patients with less severe COPD based on baseline FEV1.

The previous GOLD Guidelines for COPD suggested LABA + ICS therapy as an option for patients with a high symptom and exacerbation burden (previously known as GOLD Group D). Guidelines no longer recommend LABA + ICS therapy due to the superiority of triple inhaled therapy for exacerbations and the superiority of LAMA + LABA therapy for dyspnea.⁷ A majority of identified patients in this project were on LABA + ICS therapy alone at baseline. The ICS de-escalation recommendation resulted in a 61.5% reduction in patients on LABA + ICS therapy at 6 months. By decreasing the number of patients on LABA + ICS without LAMA, recommendations increased the number of patients on guideline-directed therapy.

Limitations

This study lacked a control group, and the rate of ICS de-escalation in patients who did not receive a pharmacist recommendation was not assessed. Therefore, it could not be determined whether the pharmacist recommendation is more effective than no recommendation. Another limitation was our inability to access records from non-VA health care facilities. This may have resulted in missed COPD exacerbations, pneumonia, and oral candidiasis prior to or following the pharmacist recommendation.

In addition, the method used to notify PCPs of the pharmacist recommendation was a CPRS alert. Clinicians often receive multiple daily alerts and may not always pay close attention to them due to alert fatigue. Early in the study, some PCPs were unknowingly omitted from the alert of the pharmacist recommendation for 10 patients due to human error. For 8 of these 10 patients, the PCP was notified of the recommendations during the 3-month follow-up period. However, 2 patients had COPD exacerbations during the 3-month follow-up period. In these cases, the PCP was not alerted to de-escalate ICS. The data for these patients were collected at 3 and 6 months in the same manner as all other patients. Also, 7 of 35 patients who were referred to a pharmacist for ICS de-escalation did not have a scheduled appointment. These patients were considered to be lost to follow-up and this may have resulted in an underestimation of the ability of pharmacists to successfully de-escalate ICS in patients with COPD.

Other studies have evaluated the efficacy of a pharmacy-driven ICS de-escalation.^8,9 Hegland et al reported ICS de-escalation for 22% of 141 eligible ambulatory patients with COPD on triple inhaled therapy following pharmacist appointments.⁸ A study by Hahn et al resulted in 63.8% of 58 patients with COPD being maintained off ICS following a pharmacist de-escalation initiative.⁹ However, these studies relied upon more time-consuming de-escalation interventions, including at least 1 phone, video, or in-person patient visit.^8,9

This project used a single chart review and templated progress note to recommend ICS de-escalation and achieved similar or improved de-escalation rates compared to previous studies.^8,9 Previous studies were conducted prior to the updated 2023 GOLD guidelines for COPD which no longer recommend LABA + ICS therapy. This project addressed ICS de-escalation in patients on LABA + ICS therapy in addition to those on triple inhaled therapy. Additionally, previous studies did not address rates of moderate to severe COPD exacerbation and adverse events to ICS following the pharmacist intervention.^8,9

This study included COPD exacerbations and cases of pneumonia or oral candidiasis as secondary outcomes to assess the safety and efficacy of the ICS de-escalation. It appeared there were similar or lower rates of COPD exacerbations, pneumonia, and oral candidiasis in those with de-escalated ICS therapy in this study. However, these secondary outcomes are exploratory and would need to be confirmed by larger studies powered to address these outcomes.

CONCLUSIONS

Pharmacist-driven ICS de-escalation may be an effective method for reducing ICS usage in veterans as seen in this study. Additional controlled studies are required to evaluate the efficacy and safety of pharmacist-driven ICS de-escalation.

Systemic glucocorticoids play an important role in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations. They are recommended to shorten recovery time and increase forced expiratory volume in 1 second (FEV1) during exacerbations.¹ However, the role of the chronic use of inhaled corticosteroids (ICSs) in the treatment of COPD is less clear.

When added to inhaled β-2 agonists and muscarinic antagonists, ICSs can decrease the risk of exacerbations.¹ However, not all patients with COPD benefit from ICS therapy. The degree of benefit an ICS can provide has been shown to correlate with eosinophil count—a marker of inflammation. The expected benefit of using an ICS increases as the eosinophil count increases.¹ Maximum benefit can be observed with eosinophil counts ≥ 300 cells/µL, and minimal benefit is observed with eosinophil counts < 100 cells/µL. Adverse effects (AEs) of ICSs include a hoarse voice, oral candidiasis, and an increased risk of pneumonia.¹ Given the risk of AEs, it is important to limit ICS use in patients who are unlikely to reap any benefits.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest the use of ICSs in patients who experience exacerbations while using long-acting β agonist (LABA) plus long-acting muscarinic antagonist (LAMA) therapy and have an eosinophil count ≥ 100 cells/µL. Switching from LABA or LAMA monotherapy to triple therapy with LAMA/LABA/ICS may be considered if patients have continued exacerbations and an eosinophil count ≥ 300 cells/µL. De-escalation of ICS therapy should be considered if patients do not meet these criteria or if patients experience ICS AEs, such as pneumonia. The patients most likely to have increased exacerbations or decreased FEV1 with ICS withdrawal are those with eosinophil counts ≥ 300 cells/µL.^1,2

Several studies have explored the effects of ICS de-escalation in real-world clinical settings. A systematic review of 11 studies indicated that de-escalation of ICS in COPD does not result in increased exacerbations.³ A prospective study by Rossi et al found that in a 6-month period, 141 of 482 patients on ICS therapy (29%) had an exacerbation. In the opposing arm of the study, 88 of 334 patients (26%) with deprescribed ICS experienced an exacerbation. The difference between these 2 groups was not statistically significant.⁴ The researchers concluded that in real-world practice, ICS withdrawal can be safe in patients at low risk of exacerbation.

About 25% of veterans (1.25 million) have been diagnosed with COPD.⁵ To address this, the US Department of Veterans Affairs (VA) and US Department of Defense published updated COPD guidelines in 2021 that specify criteria for de-escalation of ICS.⁶ Guidelines, however, may not be reflected in common clinical practice for several years following publication. The VA Academic Detailing Service (ADS) provides tools to help clinicians identify patients who may benefit from changes in treatment plans. A recent ADS focus was the implementation of a COPD dashboard, which identifies patients with COPD who are candidates for ICS de-escalation based on comorbid diagnoses, exacerbation history, and eosinophil count. VA pharmacists have an expanded role in the management of primary care disease states and are therefore well-positioned to increase adherence to guideline-directed therapy. The objective of this quality improvement project was to determine the impact of pharmacist-driven de-escalation on ICS usage in veterans with COPD.

Methods

This project was conducted in an outpatient clinic at the Robley Rex VA Medical Center beginning September 21, 2023, with a progress note in the Computerized Patient Record System (CPRS). Eligible patients were selected using the COPD Dashboard provided by ADS. The COPD Dashboard defined patients with COPD as those with ≥ 2 outpatient COPD diagnoses in the past 2 years, 1 inpatient discharge COPD diagnosis in the past year, or COPD listed as an active problem. COPD diagnoses were identified using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes (Appendix).

Candidates identified for ICS de-escalation by the dashboard were excluded if they had a history of COPD exacerbation in the previous 2 years. The dashboard identified COPD exacerbations via ICD-10 codes for COPD or acute respiratory failure for inpatient discharges, emergency department (ED) visits, urgent care visits, and community care consults with 1 of the following terms: emergency, inpatient, hospital, urgent, ED (self). The COPD dashboard excluded patients with a diagnosis of asthma.

After patients were selected, they were screened for additional exclusion criteria. Patients were excluded if a pulmonary care practitioner managed their COPD; if identified via an active pulmonary consult in CPRS; if a non-VA clinician prescribed their ICS; or if they were being treated with roflumilast, theophylline, or chronic azithromycin. Individuals taking these 3 drugs were excluded due to potential severe and/or refractory COPD. Patients also were excluded if they: (1) had prior ICS de-escalation failure (defined as a COPD exacerbation following ICS de-escalation that resulted in ICS resumption); (2) had a COPD exacerbation requiring systemic corticosteroids or antibiotics in the previous year; (3) had active lung cancer; (4) did not have any eosinophil levels in CPRS within the previous 2 years; or (5) had any eosinophil levels ≥ 300 cells/µL in the previous year.

Each patient who met the inclusion criteria and was not excluded received a focused medication review by a pharmacist who created a templated progress note, with patient-specific recommendations, that was entered in the CPRS (eAppendix). The recommendations were also attached as an addendum to the patient’s last primary care visit note, and the primary care practitioner (PCP) was alerted via CPRS to consider ICS de-escalation and non-ICS alternatives. Tapering of ICS therapy was offered as an option to de-escalate if abrupt discontinuation was deemed inappropriate. PCPs were also prompted to consider referral to a primary care clinical pharmacy specialist for management and follow-up of ICS de-escalation.

The primary outcome was the number of patients with de-escalated ICS at 3 and 6 months following the recommendation. Secondary outcomes included the number of: patients who were no longer prescribed an ICS or who had a non-ICS alternative initiated at a pharmacist’s recommendation; patients who were referred to a primary care clinical pharmacy specialist for ICS de-escalation; COPD exacerbations requiring systemic steroids or antibiotics, or requiring an ED visit, inpatient admission, or urgent-care clinic visit; and cases of pneumonia or oral candidiasis. Primary and secondary outcomes were evaluated via chart review in CPRS. For secondary outcomes of pneumonia and COPD exacerbation, identification was made by documented diagnosis in CPRS. For continuous data such as age, the mean was calculated.

Results

Pharmacist ICS de-escalation recommendations were made between September 21, 2023, and November 19, 2023, for 106 patients. The mean age was 72 years and 99 (93%) patients were male (Table 1). Forty-one (39%) of the patients used tobacco at the time of the study. FEV1 was available for 69 patients with a mean of 63% (GOLD grade 2).¹ Based on FEV1 values, 16 patients had mild COPD (GOLD grade 1), 37 patients had moderate COPD (GOLD grade 2), 14 patients had severe COPD (GOLD grade 3), and 2 patients had very severe COPD (GOLD grade 4).¹ Thirty-four patients received LABA + LAMA + ICS, 65 received LABA + ICS, 2 received LAMA + ICS, and 5 received ICS monotherapy. The most common dose of ICS was a moderate dose (Table 2). Only 2 patients had an ICS AE in the previous year.

ICS de-escalation recommendations resulted in ICS de-escalation in 50 (47.2%) and 62 (58.5%) patients at 3 and 6 months, respectively. The 6-month ICS de-escalation rate by ICS dose at baseline was 72.2% (high dose), 60.0% (moderate), and 30.8% (low). De-escalation at 6 months by GOLD grade at baseline was 56.3% (9 of 16 patients, GOLD 1), 64.9% (24 of 37 patients, GOLD 2), 50% (7 of 14 patients, GOLD 3), and 50% (1 of 2 patients, GOLD 4). Six months after the ICS de-escalation recommendation appeared in the CPRS, the percentage of patients on LABA + ICS therapy dropped from 65 patients (61.3%) at baseline to 25 patients (23.6%).

Secondary outcomes were assessed at 3 and 6 months following the recommendation. Most patients with de-escalated ICS had their ICS discontinued and a non-ICS alternative initiated per pharmacist recommendations. At 6 months, 39 patients (36.8%) patients were referred to a patient aligned care team (PACT) pharmacist for de-escalation. Of the 39 patients referred to pharmacists, 69.2% (27 patients) were de-escalated; this compared to 52.2% (35 patients) who were not referred to pharmacists (Table 3).

ICS use increases the risk of pneumonia.¹ At 6 months, 11 patients were diagnosed with pneumonia; 3 patients were diagnosed with pneumonia twice, resulting in a total of 14 cases. Ten cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation. One patient had a documented case of oral candidiasis that occurred while on ICS therapy; no patients with discontinued ICS were diagnosed with oral candidiasis. In addition, 10 patients had COPD exacerbations; however no patients had exacerbations both before and after de-escalation. Six patients were on ICS therapy when they experienced an exacerbation, and 4 patients had an exacerbation after ICS de-escalation.

Discussion

More than half of patients receiving the pharmacist intervention achieved the primary outcome of ICS de-escalation at 6 months. Furthermore, a larger percentage of patients referred to pharmacists for the management of ICS de-escalation successfully achieved de-escalation compared to those who were not referred. These outcomes reflect the important role pharmacists can play in identifying appropriate candidates for ICS de-escalation and assisting in the management of ICS de-escalation. Patients referred to pharmacists also received other services such as smoking cessation pharmacotherapy and counseling on inhaler technique and adherence. These interventions can support improved COPD clinical outcomes.

The purpose of de-escalating ICS therapy is to reduce the risk of AEs such as pneumonia and oral candidiasis.¹ The secondary outcomes of this study support previous evidence that patients who have de-escalated ICS therapy may have reduced risk of AEs compared to those who remain on ICS therapy.³ Specifically, of the 14 cases of pneumonia that occurred during the study, 10 cases occurred while patients were on ICS and 4 cases occurred following ICS de-escalation.

ICS de-escalation may increase risk of increased COPD exacerbations.¹ However, the secondary outcomes of this study do not indicate that those with de-escalated ICS had more COPD exacerbations compared to those who continued on ICS. Pharmacists’ recommendations were more effective for patients with less severe COPD based on baseline FEV1.

The previous GOLD Guidelines for COPD suggested LABA + ICS therapy as an option for patients with a high symptom and exacerbation burden (previously known as GOLD Group D). Guidelines no longer recommend LABA + ICS therapy due to the superiority of triple inhaled therapy for exacerbations and the superiority of LAMA + LABA therapy for dyspnea.⁷ A majority of identified patients in this project were on LABA + ICS therapy alone at baseline. The ICS de-escalation recommendation resulted in a 61.5% reduction in patients on LABA + ICS therapy at 6 months. By decreasing the number of patients on LABA + ICS without LAMA, recommendations increased the number of patients on guideline-directed therapy.

Limitations

This study lacked a control group, and the rate of ICS de-escalation in patients who did not receive a pharmacist recommendation was not assessed. Therefore, it could not be determined whether the pharmacist recommendation is more effective than no recommendation. Another limitation was our inability to access records from non-VA health care facilities. This may have resulted in missed COPD exacerbations, pneumonia, and oral candidiasis prior to or following the pharmacist recommendation.

In addition, the method used to notify PCPs of the pharmacist recommendation was a CPRS alert. Clinicians often receive multiple daily alerts and may not always pay close attention to them due to alert fatigue. Early in the study, some PCPs were unknowingly omitted from the alert of the pharmacist recommendation for 10 patients due to human error. For 8 of these 10 patients, the PCP was notified of the recommendations during the 3-month follow-up period. However, 2 patients had COPD exacerbations during the 3-month follow-up period. In these cases, the PCP was not alerted to de-escalate ICS. The data for these patients were collected at 3 and 6 months in the same manner as all other patients. Also, 7 of 35 patients who were referred to a pharmacist for ICS de-escalation did not have a scheduled appointment. These patients were considered to be lost to follow-up and this may have resulted in an underestimation of the ability of pharmacists to successfully de-escalate ICS in patients with COPD.

Other studies have evaluated the efficacy of a pharmacy-driven ICS de-escalation.^8,9 Hegland et al reported ICS de-escalation for 22% of 141 eligible ambulatory patients with COPD on triple inhaled therapy following pharmacist appointments.⁸ A study by Hahn et al resulted in 63.8% of 58 patients with COPD being maintained off ICS following a pharmacist de-escalation initiative.⁹ However, these studies relied upon more time-consuming de-escalation interventions, including at least 1 phone, video, or in-person patient visit.^8,9

This project used a single chart review and templated progress note to recommend ICS de-escalation and achieved similar or improved de-escalation rates compared to previous studies.^8,9 Previous studies were conducted prior to the updated 2023 GOLD guidelines for COPD which no longer recommend LABA + ICS therapy. This project addressed ICS de-escalation in patients on LABA + ICS therapy in addition to those on triple inhaled therapy. Additionally, previous studies did not address rates of moderate to severe COPD exacerbation and adverse events to ICS following the pharmacist intervention.^8,9

This study included COPD exacerbations and cases of pneumonia or oral candidiasis as secondary outcomes to assess the safety and efficacy of the ICS de-escalation. It appeared there were similar or lower rates of COPD exacerbations, pneumonia, and oral candidiasis in those with de-escalated ICS therapy in this study. However, these secondary outcomes are exploratory and would need to be confirmed by larger studies powered to address these outcomes.

CONCLUSIONS

Pharmacist-driven ICS de-escalation may be an effective method for reducing ICS usage in veterans as seen in this study. Additional controlled studies are required to evaluate the efficacy and safety of pharmacist-driven ICS de-escalation.

THE DIAGNOSIS: Folliculitis Decalvans

Biopsy results revealed a brisk perifollicular and intrafollicular mixed inflammatory infiltrate comprising lymphocytes, neutrophils, and plasma cells filling the upper dermis and encircling dilated hair follicles. Elastic stain (Verhoeff-van Gieson) demonstrated loss of elastic fibers in areas of scarring. Periodic acid–Schiff with diastase staining was negative for fungal elements, while Gram staining revealed colonies of bacterial cocci in the stratum corneum and within the hair follicles. Immunofluorescence was unremarkable, and culture revealed methicillin-sensitive Staphylococcus aureus, leading to a diagnosis of folliculitis decalvans (FD). The patient was treated with doxycycline 100 mg twice daily and received intralesional triamcinolone 2.5 mg/mL (total volume, 2 mL) every 6 weeks with considerable improvement in pustules, erythema, and scaling (Figure). While not yet in complete remission, our patient demonstrated short regrowing hairs in areas of incomplete scarring and focal remaining perifollicular erythema and scale along the midline frontal scalp 5 months after initial presentation.

Folliculitis decalvans is an uncommon subtype of cicatricial alopecia that may mimic other forms of alopecia. Cicatricial alopecia often is difficult to diagnose due to its overlapping clinical characteristics, but early diagnosis is essential for appropriate management and prevention of further permanent hair loss. Traditionally classified as a primary neutrophilic cicatricial alopecia, lymphocyte-predominant variants of FD now are recognized.¹

Patients with FD typically present with patchy scarring alopecia at the vertex scalp that gradually expands and may demonstrate secondary features of follicular tufting and pustules.^1-3 While the epidemiology of FD is poorly characterized, Vañó-Galván et al⁴ reported that FD accounted for 2.8% of all alopecia cases and 10.5% of cicatricial alopecia cases in a multicenter study of 2835 patients. The pathophysiology of FD still is under investigation but is thought to result from a dysregulated immune response to a chronic bacterial infection (eg, S aureus), with resulting neutrophilpredominant inflammation in early stages.^1-3 Vañó-Galván et al⁴ reported that, among 35 patients with FD cultured for bacteria, 74% (26/35) returned positive results, 96% (25/26) of which grew S aureus.⁵

A systematic review of 20 studies that included 263 patients found rifampin and clindamycin to be the most common treatments for FD; however, there is insufficient evidence to determine if this treatment is the most effective.⁶ In our patient, clindamycin was avoided due to its propensity to negatively alter the gut microbiome long term.⁷ Other therapies such as oral tetracyclines, high-potency topical steroids, and intralesional triamcinolone also can be used to achieve disease remission.^5,6 Other treatments such as isotretinoin, red-light photodynamic therapy, tacrolimus, and external beam radiation have been reported in the literature but vary in efficacy.⁶ Our patient improved on a regimen of topical benzoyl peroxide wash, oral doxycycline, and intralesional triamcinolone.

Notably, FD may share clinical features with other causes of cicatricial alopecia. In our patient, FD mimicked other entities including discoid lupus erythematosus, frontal fibrosing alopecia, dissecting cellulitis, and erosive pustular dermatosis (Table).^1-14 Discoid lupus erythematosus manifests as round hypopigmented and hyperpigmented plaques with associated atrophy, perifollicular erythema, and follicular plugging. Frontal fibrosing alopecia is a primary lymphocytic scarring alopecia that manifests in a bandlike linear distribution over the frontal scalp and may involve the temporal scalp, posterior hairline, and/or eyebrows. Isolated hairs (known as lonely hairs) often are seen. Dissecting cellulitis is characterized by boggy nodules associated with alopecia on the scalp without notable epidermal change, although pustules and sinus tracts may develop.⁹ Erosive pustular dermatosis is a diagnosis of exclusion but often is seen in older adults with chronic sun damage and clinically manifests with eroded plaques with adherent crusts.¹⁰

While our patient presented with several overlapping clinical features, including progressive hair loss along the frontal scalp in a bandlike pattern suspicious for frontal fibrosing alopecia as well as atrophic depigmented plaques with adherent peripheral scaling suspicious for discoid lupus erythematosus, the presence of pustules was an important clue. The biopsy demonstrating a mixed infiltrate inclusive of neutrophils confirmed the diagnosis of FD.

THE DIAGNOSIS: Folliculitis Decalvans

Biopsy results revealed a brisk perifollicular and intrafollicular mixed inflammatory infiltrate comprising lymphocytes, neutrophils, and plasma cells filling the upper dermis and encircling dilated hair follicles. Elastic stain (Verhoeff-van Gieson) demonstrated loss of elastic fibers in areas of scarring. Periodic acid–Schiff with diastase staining was negative for fungal elements, while Gram staining revealed colonies of bacterial cocci in the stratum corneum and within the hair follicles. Immunofluorescence was unremarkable, and culture revealed methicillin-sensitive Staphylococcus aureus, leading to a diagnosis of folliculitis decalvans (FD). The patient was treated with doxycycline 100 mg twice daily and received intralesional triamcinolone 2.5 mg/mL (total volume, 2 mL) every 6 weeks with considerable improvement in pustules, erythema, and scaling (Figure). While not yet in complete remission, our patient demonstrated short regrowing hairs in areas of incomplete scarring and focal remaining perifollicular erythema and scale along the midline frontal scalp 5 months after initial presentation.

Folliculitis decalvans is an uncommon subtype of cicatricial alopecia that may mimic other forms of alopecia. Cicatricial alopecia often is difficult to diagnose due to its overlapping clinical characteristics, but early diagnosis is essential for appropriate management and prevention of further permanent hair loss. Traditionally classified as a primary neutrophilic cicatricial alopecia, lymphocyte-predominant variants of FD now are recognized.¹

Patients with FD typically present with patchy scarring alopecia at the vertex scalp that gradually expands and may demonstrate secondary features of follicular tufting and pustules.^1-3 While the epidemiology of FD is poorly characterized, Vañó-Galván et al⁴ reported that FD accounted for 2.8% of all alopecia cases and 10.5% of cicatricial alopecia cases in a multicenter study of 2835 patients. The pathophysiology of FD still is under investigation but is thought to result from a dysregulated immune response to a chronic bacterial infection (eg, S aureus), with resulting neutrophilpredominant inflammation in early stages.^1-3 Vañó-Galván et al⁴ reported that, among 35 patients with FD cultured for bacteria, 74% (26/35) returned positive results, 96% (25/26) of which grew S aureus.⁵

A systematic review of 20 studies that included 263 patients found rifampin and clindamycin to be the most common treatments for FD; however, there is insufficient evidence to determine if this treatment is the most effective.⁶ In our patient, clindamycin was avoided due to its propensity to negatively alter the gut microbiome long term.⁷ Other therapies such as oral tetracyclines, high-potency topical steroids, and intralesional triamcinolone also can be used to achieve disease remission.^5,6 Other treatments such as isotretinoin, red-light photodynamic therapy, tacrolimus, and external beam radiation have been reported in the literature but vary in efficacy.⁶ Our patient improved on a regimen of topical benzoyl peroxide wash, oral doxycycline, and intralesional triamcinolone.

Notably, FD may share clinical features with other causes of cicatricial alopecia. In our patient, FD mimicked other entities including discoid lupus erythematosus, frontal fibrosing alopecia, dissecting cellulitis, and erosive pustular dermatosis (Table).^1-14 Discoid lupus erythematosus manifests as round hypopigmented and hyperpigmented plaques with associated atrophy, perifollicular erythema, and follicular plugging. Frontal fibrosing alopecia is a primary lymphocytic scarring alopecia that manifests in a bandlike linear distribution over the frontal scalp and may involve the temporal scalp, posterior hairline, and/or eyebrows. Isolated hairs (known as lonely hairs) often are seen. Dissecting cellulitis is characterized by boggy nodules associated with alopecia on the scalp without notable epidermal change, although pustules and sinus tracts may develop.⁹ Erosive pustular dermatosis is a diagnosis of exclusion but often is seen in older adults with chronic sun damage and clinically manifests with eroded plaques with adherent crusts.¹⁰

While our patient presented with several overlapping clinical features, including progressive hair loss along the frontal scalp in a bandlike pattern suspicious for frontal fibrosing alopecia as well as atrophic depigmented plaques with adherent peripheral scaling suspicious for discoid lupus erythematosus, the presence of pustules was an important clue. The biopsy demonstrating a mixed infiltrate inclusive of neutrophils confirmed the diagnosis of FD.

THE DIAGNOSIS: Folliculitis Decalvans

Biopsy results revealed a brisk perifollicular and intrafollicular mixed inflammatory infiltrate comprising lymphocytes, neutrophils, and plasma cells filling the upper dermis and encircling dilated hair follicles. Elastic stain (Verhoeff-van Gieson) demonstrated loss of elastic fibers in areas of scarring. Periodic acid–Schiff with diastase staining was negative for fungal elements, while Gram staining revealed colonies of bacterial cocci in the stratum corneum and within the hair follicles. Immunofluorescence was unremarkable, and culture revealed methicillin-sensitive Staphylococcus aureus, leading to a diagnosis of folliculitis decalvans (FD). The patient was treated with doxycycline 100 mg twice daily and received intralesional triamcinolone 2.5 mg/mL (total volume, 2 mL) every 6 weeks with considerable improvement in pustules, erythema, and scaling (Figure). While not yet in complete remission, our patient demonstrated short regrowing hairs in areas of incomplete scarring and focal remaining perifollicular erythema and scale along the midline frontal scalp 5 months after initial presentation.

Folliculitis decalvans is an uncommon subtype of cicatricial alopecia that may mimic other forms of alopecia. Cicatricial alopecia often is difficult to diagnose due to its overlapping clinical characteristics, but early diagnosis is essential for appropriate management and prevention of further permanent hair loss. Traditionally classified as a primary neutrophilic cicatricial alopecia, lymphocyte-predominant variants of FD now are recognized.¹

Patients with FD typically present with patchy scarring alopecia at the vertex scalp that gradually expands and may demonstrate secondary features of follicular tufting and pustules.^1-3 While the epidemiology of FD is poorly characterized, Vañó-Galván et al⁴ reported that FD accounted for 2.8% of all alopecia cases and 10.5% of cicatricial alopecia cases in a multicenter study of 2835 patients. The pathophysiology of FD still is under investigation but is thought to result from a dysregulated immune response to a chronic bacterial infection (eg, S aureus), with resulting neutrophilpredominant inflammation in early stages.^1-3 Vañó-Galván et al⁴ reported that, among 35 patients with FD cultured for bacteria, 74% (26/35) returned positive results, 96% (25/26) of which grew S aureus.⁵

A systematic review of 20 studies that included 263 patients found rifampin and clindamycin to be the most common treatments for FD; however, there is insufficient evidence to determine if this treatment is the most effective.⁶ In our patient, clindamycin was avoided due to its propensity to negatively alter the gut microbiome long term.⁷ Other therapies such as oral tetracyclines, high-potency topical steroids, and intralesional triamcinolone also can be used to achieve disease remission.^5,6 Other treatments such as isotretinoin, red-light photodynamic therapy, tacrolimus, and external beam radiation have been reported in the literature but vary in efficacy.⁶ Our patient improved on a regimen of topical benzoyl peroxide wash, oral doxycycline, and intralesional triamcinolone.

Notably, FD may share clinical features with other causes of cicatricial alopecia. In our patient, FD mimicked other entities including discoid lupus erythematosus, frontal fibrosing alopecia, dissecting cellulitis, and erosive pustular dermatosis (Table).^1-14 Discoid lupus erythematosus manifests as round hypopigmented and hyperpigmented plaques with associated atrophy, perifollicular erythema, and follicular plugging. Frontal fibrosing alopecia is a primary lymphocytic scarring alopecia that manifests in a bandlike linear distribution over the frontal scalp and may involve the temporal scalp, posterior hairline, and/or eyebrows. Isolated hairs (known as lonely hairs) often are seen. Dissecting cellulitis is characterized by boggy nodules associated with alopecia on the scalp without notable epidermal change, although pustules and sinus tracts may develop.⁹ Erosive pustular dermatosis is a diagnosis of exclusion but often is seen in older adults with chronic sun damage and clinically manifests with eroded plaques with adherent crusts.¹⁰

While our patient presented with several overlapping clinical features, including progressive hair loss along the frontal scalp in a bandlike pattern suspicious for frontal fibrosing alopecia as well as atrophic depigmented plaques with adherent peripheral scaling suspicious for discoid lupus erythematosus, the presence of pustules was an important clue. The biopsy demonstrating a mixed infiltrate inclusive of neutrophils confirmed the diagnosis of FD.

The original four HPEER Advanced Fellowship sites were established by the Department of Veterans Affairs (VA) Office of Academic Affiliation in 2014, and expanded in 2020 to include 8 sites and a national coordinating center with leadership shared between VA facilities in Houston and White River Junction. The VA invests heavily in training the nation’s healthcare professionals. The mission of HPEER is to develop leaders who can educate, evaluate, and innovate in Health Professions Education for the VA and the nation. All HPEER sites take part in a nationally coordinated curriculum covering topics in curriculum design, learner assessment, leadership, interprofessional education, as well as scholarship and educational research.

As part of the national HPEER curriculum covering scholarship and educational research, and in concert with Wednesday, May 14, 2025 VA Research Week 2025, HPEER organized a joint conference with the Center for Health Professions Education at the Uniformed Services University of the Health Sciences (USUHS). This interagency online event included poster sessions and oral presentations from HPEER fellows and students in USUHS certificate and graduate degree programs.

Education scholarship is broad, ranging from descriptions of curricular innovations and works in progress to advanced research using techniques drawn from psychology, sociology, anthropology, economics, and other scientific disciplines. The abstracts presented here summarize some of the work being done by HPEER fellows. Dougherty et al (Boston) described a project to create a primer outlining methodology for conducting and interpreting cost-effectiveness evaluations in the context of proposed HPE innovations. Cohen et al (Cleveland) found reduction in potentially problematic orders in the context of life-sustaining treatment following a multifaceted intervention program. Sorenson (Dublin, Georgia) reported an expanded Tai Chi program that included modifications allowing seated positions for veterans with mobility limitations. Young et al (Dublin) described an interprofessional curriculum to strengthen communication between nurses and social workers in their conversations with women veterans living in rural settings. Misedah-Robinson et al (Houston) showed that a new training program strengthened coordinators’ self-reports of preparedness and confidence in their ability to support veterans who have experienced human trafficking. Tovar et al (Salt Lake City) describe a methodology for using data from the VHA Corporate Data Warehouse to optimize schedules of HPE students assigned to VA clinical rotations. Yanez et al (San Francisco) presented initial observations of learner-centered outcomes following participation in a new multidisciplinary integrative health elective. Resto et al (West Haven) reported that implementation of self-serve kiosks increased distribution of substance use harm reduction resources beyond usual clinical care.

A second joint conference between VA HPEER and USUHS is planned for VA Research Week 2026; we look forward to the abstracts that will be produced by this new cohort of fellows, as well as to the future scholarship and contributions to the field that will be made by alumni of the HPEER Advanced Fellowship.

The original four HPEER Advanced Fellowship sites were established by the Department of Veterans Affairs (VA) Office of Academic Affiliation in 2014, and expanded in 2020 to include 8 sites and a national coordinating center with leadership shared between VA facilities in Houston and White River Junction. The VA invests heavily in training the nation’s healthcare professionals. The mission of HPEER is to develop leaders who can educate, evaluate, and innovate in Health Professions Education for the VA and the nation. All HPEER sites take part in a nationally coordinated curriculum covering topics in curriculum design, learner assessment, leadership, interprofessional education, as well as scholarship and educational research.

As part of the national HPEER curriculum covering scholarship and educational research, and in concert with Wednesday, May 14, 2025 VA Research Week 2025, HPEER organized a joint conference with the Center for Health Professions Education at the Uniformed Services University of the Health Sciences (USUHS). This interagency online event included poster sessions and oral presentations from HPEER fellows and students in USUHS certificate and graduate degree programs.

Education scholarship is broad, ranging from descriptions of curricular innovations and works in progress to advanced research using techniques drawn from psychology, sociology, anthropology, economics, and other scientific disciplines. The abstracts presented here summarize some of the work being done by HPEER fellows. Dougherty et al (Boston) described a project to create a primer outlining methodology for conducting and interpreting cost-effectiveness evaluations in the context of proposed HPE innovations. Cohen et al (Cleveland) found reduction in potentially problematic orders in the context of life-sustaining treatment following a multifaceted intervention program. Sorenson (Dublin, Georgia) reported an expanded Tai Chi program that included modifications allowing seated positions for veterans with mobility limitations. Young et al (Dublin) described an interprofessional curriculum to strengthen communication between nurses and social workers in their conversations with women veterans living in rural settings. Misedah-Robinson et al (Houston) showed that a new training program strengthened coordinators’ self-reports of preparedness and confidence in their ability to support veterans who have experienced human trafficking. Tovar et al (Salt Lake City) describe a methodology for using data from the VHA Corporate Data Warehouse to optimize schedules of HPE students assigned to VA clinical rotations. Yanez et al (San Francisco) presented initial observations of learner-centered outcomes following participation in a new multidisciplinary integrative health elective. Resto et al (West Haven) reported that implementation of self-serve kiosks increased distribution of substance use harm reduction resources beyond usual clinical care.

A second joint conference between VA HPEER and USUHS is planned for VA Research Week 2026; we look forward to the abstracts that will be produced by this new cohort of fellows, as well as to the future scholarship and contributions to the field that will be made by alumni of the HPEER Advanced Fellowship.

The original four HPEER Advanced Fellowship sites were established by the Department of Veterans Affairs (VA) Office of Academic Affiliation in 2014, and expanded in 2020 to include 8 sites and a national coordinating center with leadership shared between VA facilities in Houston and White River Junction. The VA invests heavily in training the nation’s healthcare professionals. The mission of HPEER is to develop leaders who can educate, evaluate, and innovate in Health Professions Education for the VA and the nation. All HPEER sites take part in a nationally coordinated curriculum covering topics in curriculum design, learner assessment, leadership, interprofessional education, as well as scholarship and educational research.

As part of the national HPEER curriculum covering scholarship and educational research, and in concert with Wednesday, May 14, 2025 VA Research Week 2025, HPEER organized a joint conference with the Center for Health Professions Education at the Uniformed Services University of the Health Sciences (USUHS). This interagency online event included poster sessions and oral presentations from HPEER fellows and students in USUHS certificate and graduate degree programs.

Education scholarship is broad, ranging from descriptions of curricular innovations and works in progress to advanced research using techniques drawn from psychology, sociology, anthropology, economics, and other scientific disciplines. The abstracts presented here summarize some of the work being done by HPEER fellows. Dougherty et al (Boston) described a project to create a primer outlining methodology for conducting and interpreting cost-effectiveness evaluations in the context of proposed HPE innovations. Cohen et al (Cleveland) found reduction in potentially problematic orders in the context of life-sustaining treatment following a multifaceted intervention program. Sorenson (Dublin, Georgia) reported an expanded Tai Chi program that included modifications allowing seated positions for veterans with mobility limitations. Young et al (Dublin) described an interprofessional curriculum to strengthen communication between nurses and social workers in their conversations with women veterans living in rural settings. Misedah-Robinson et al (Houston) showed that a new training program strengthened coordinators’ self-reports of preparedness and confidence in their ability to support veterans who have experienced human trafficking. Tovar et al (Salt Lake City) describe a methodology for using data from the VHA Corporate Data Warehouse to optimize schedules of HPE students assigned to VA clinical rotations. Yanez et al (San Francisco) presented initial observations of learner-centered outcomes following participation in a new multidisciplinary integrative health elective. Resto et al (West Haven) reported that implementation of self-serve kiosks increased distribution of substance use harm reduction resources beyond usual clinical care.

A second joint conference between VA HPEER and USUHS is planned for VA Research Week 2026; we look forward to the abstracts that will be produced by this new cohort of fellows, as well as to the future scholarship and contributions to the field that will be made by alumni of the HPEER Advanced Fellowship.

Background

Veterans may have a greater risk of experiencing human trafficking (HT) than the general population because of social aspects of health, including housing insecurity, justice involvement, food insecurity, and adverse childhood events.^1-4 Since 2023, the U.S. Department of Veterans Affairs (VA) has explored veterans’ experiences of HT through the Anti-Human Trafficking (AHT) Pilot Project.  This quality improvement project evaluated: 1) development of clinician AHT training materials to enhance identification and response to Veterans experiencing HT, and 2) educational resources aimed at raising awareness tailored to veterans and clinicians.

Methods

South Central Mental Illness Research, Education and Clinical Center (SCMIRECC) facilitated two focus group discussions with AHT coordinators implementing the pilot at six sites. Based on discussions and leadership input, SCMIRECC developed a training curriculum, with bi-weekly readings culminating in a two-hour workshop. Training evaluation followed Kirkpatrick’s model using questions adapted from the Provider Responses, Treatment, and Care for Trafficked People (PROTECT) Survey.^5,6 Veteran-facing materials, including a brochure and whiteboard video, were reviewed by two Veteran Consumer Advisory Boards (CAB). The brochures, whiteboard video, and awareness modules were developed and revised based on feedback from focus group discussions. VA Central Office cleared all materials.

Results

Coordinators were satisfied with the training (mean, 4.20). After the training, none of the coordinators (n = 6) felt unprepared to assist Veterans (pre-training mean, 2.25; post-training mean, 1.40), and confidence in documentation improved (pre-training mean, 3.00; post-training mean, 3.40). Veteran CAB members recommended simplified language and veteran-centered messaging. The coordinators found the brochures and training useful. Recommendations included adding more representation to brochure covers, advanced training, a list of commonly asked questions, and a simplified screening tool. Barriers included delays in material development due to language guidance under recent executive orders.

Conclusions

The AHT training improved coordinators’ preparedness and confidence in supporting Veterans with trafficking experiences. Feedback emphasized the value of concise, Veteran-centered materials and a practical HT screening tool. These findings support the continued implementation of AHT education across VA settings to enhance identification and response for Veterans at risk of HT.

Background

Veterans may have a greater risk of experiencing human trafficking (HT) than the general population because of social aspects of health, including housing insecurity, justice involvement, food insecurity, and adverse childhood events.^1-4 Since 2023, the U.S. Department of Veterans Affairs (VA) has explored veterans’ experiences of HT through the Anti-Human Trafficking (AHT) Pilot Project.  This quality improvement project evaluated: 1) development of clinician AHT training materials to enhance identification and response to Veterans experiencing HT, and 2) educational resources aimed at raising awareness tailored to veterans and clinicians.

Methods

South Central Mental Illness Research, Education and Clinical Center (SCMIRECC) facilitated two focus group discussions with AHT coordinators implementing the pilot at six sites. Based on discussions and leadership input, SCMIRECC developed a training curriculum, with bi-weekly readings culminating in a two-hour workshop. Training evaluation followed Kirkpatrick’s model using questions adapted from the Provider Responses, Treatment, and Care for Trafficked People (PROTECT) Survey.^5,6 Veteran-facing materials, including a brochure and whiteboard video, were reviewed by two Veteran Consumer Advisory Boards (CAB). The brochures, whiteboard video, and awareness modules were developed and revised based on feedback from focus group discussions. VA Central Office cleared all materials.

Results

Coordinators were satisfied with the training (mean, 4.20). After the training, none of the coordinators (n = 6) felt unprepared to assist Veterans (pre-training mean, 2.25; post-training mean, 1.40), and confidence in documentation improved (pre-training mean, 3.00; post-training mean, 3.40). Veteran CAB members recommended simplified language and veteran-centered messaging. The coordinators found the brochures and training useful. Recommendations included adding more representation to brochure covers, advanced training, a list of commonly asked questions, and a simplified screening tool. Barriers included delays in material development due to language guidance under recent executive orders.

Conclusions

The AHT training improved coordinators’ preparedness and confidence in supporting Veterans with trafficking experiences. Feedback emphasized the value of concise, Veteran-centered materials and a practical HT screening tool. These findings support the continued implementation of AHT education across VA settings to enhance identification and response for Veterans at risk of HT.

Background

Veterans may have a greater risk of experiencing human trafficking (HT) than the general population because of social aspects of health, including housing insecurity, justice involvement, food insecurity, and adverse childhood events.^1-4 Since 2023, the U.S. Department of Veterans Affairs (VA) has explored veterans’ experiences of HT through the Anti-Human Trafficking (AHT) Pilot Project.  This quality improvement project evaluated: 1) development of clinician AHT training materials to enhance identification and response to Veterans experiencing HT, and 2) educational resources aimed at raising awareness tailored to veterans and clinicians.

Methods

South Central Mental Illness Research, Education and Clinical Center (SCMIRECC) facilitated two focus group discussions with AHT coordinators implementing the pilot at six sites. Based on discussions and leadership input, SCMIRECC developed a training curriculum, with bi-weekly readings culminating in a two-hour workshop. Training evaluation followed Kirkpatrick’s model using questions adapted from the Provider Responses, Treatment, and Care for Trafficked People (PROTECT) Survey.^5,6 Veteran-facing materials, including a brochure and whiteboard video, were reviewed by two Veteran Consumer Advisory Boards (CAB). The brochures, whiteboard video, and awareness modules were developed and revised based on feedback from focus group discussions. VA Central Office cleared all materials.

Results

Coordinators were satisfied with the training (mean, 4.20). After the training, none of the coordinators (n = 6) felt unprepared to assist Veterans (pre-training mean, 2.25; post-training mean, 1.40), and confidence in documentation improved (pre-training mean, 3.00; post-training mean, 3.40). Veteran CAB members recommended simplified language and veteran-centered messaging. The coordinators found the brochures and training useful. Recommendations included adding more representation to brochure covers, advanced training, a list of commonly asked questions, and a simplified screening tool. Barriers included delays in material development due to language guidance under recent executive orders.

Conclusions

The AHT training improved coordinators’ preparedness and confidence in supporting Veterans with trafficking experiences. Feedback emphasized the value of concise, Veteran-centered materials and a practical HT screening tool. These findings support the continued implementation of AHT education across VA settings to enhance identification and response for Veterans at risk of HT.

Background

The Accreditation Council for Graduate Medical Education (ACGME) mandates an 80-hour weekly work limit for residents.¹ In contrast, decisions regarding undergraduate medical education (UME) are strongly influenced locally, with individual institutions setting academic policy for students. These differences in oversight reflect fundamental differences in residents’ and students’ roles in patient care, power, and responsibility. Considering rotation schedules, internal medicine (IM) clerkship directors have discussed the relative value of weekend vs weekday duty during inpatient rotations, a scheduling topic of interest to students as well, though these conversations are limited by a lack of knowledge regarding admission patterns. Addressing this information gap would inform policy decisions.

The Veterans Health Administration (VHA) is uniquely positioned to address questions about UME clinical experiences nationwide: annually, over 118,000 students representing 97% of US medical schools train at VHA facilities.^2,3 We aim to compare the number and variety of patient encounter opportunities presenting during inpatient VHA IM rotations on weekdays versus weekends to inform policy decisions for UME rotation schedules.

Innovation

The VHA Corporate Data Warehouse will be queried for all admissions, diagnoses, and length of stay on inpatient IM services at the 420 VHA hospitals affiliated with US medical schools from 2016-2026. We will aggregate case data for day of week, floor, hospital, and Veteran Integrated Service Network (VISN), and determine number of admissions by weekday (Monday-Friday) and weekend (Saturday-Sunday). Weekday vs. weekend admission data will be compared using generalized mixed effects models for clustered longitudinal data. Heterogeneity across hospitals and VISNs will be explored to examine unique regional trends.

Results

We have drafted strategies to query and curate relevant datasets, developed a preliminary analysis plan, and await data deployment from VHA data stewards.

Conclusions

We believe this will be the first VHA-wide evaluation of patient encounter trends on IM services to examine potential training experiences for medical students. This will increase understanding of the critical role VHA has in developing the nations’ healthcare workforce, and how patterns of opportunities for clinical education may be distributed over time, informing decisions about rotation schedules to maximize students’ abilities to interact with, learn from, and serve our nation’s veterans

Background

The Accreditation Council for Graduate Medical Education (ACGME) mandates an 80-hour weekly work limit for residents.¹ In contrast, decisions regarding undergraduate medical education (UME) are strongly influenced locally, with individual institutions setting academic policy for students. These differences in oversight reflect fundamental differences in residents’ and students’ roles in patient care, power, and responsibility. Considering rotation schedules, internal medicine (IM) clerkship directors have discussed the relative value of weekend vs weekday duty during inpatient rotations, a scheduling topic of interest to students as well, though these conversations are limited by a lack of knowledge regarding admission patterns. Addressing this information gap would inform policy decisions.

The Veterans Health Administration (VHA) is uniquely positioned to address questions about UME clinical experiences nationwide: annually, over 118,000 students representing 97% of US medical schools train at VHA facilities.^2,3 We aim to compare the number and variety of patient encounter opportunities presenting during inpatient VHA IM rotations on weekdays versus weekends to inform policy decisions for UME rotation schedules.

Innovation

The VHA Corporate Data Warehouse will be queried for all admissions, diagnoses, and length of stay on inpatient IM services at the 420 VHA hospitals affiliated with US medical schools from 2016-2026. We will aggregate case data for day of week, floor, hospital, and Veteran Integrated Service Network (VISN), and determine number of admissions by weekday (Monday-Friday) and weekend (Saturday-Sunday). Weekday vs. weekend admission data will be compared using generalized mixed effects models for clustered longitudinal data. Heterogeneity across hospitals and VISNs will be explored to examine unique regional trends.

Results

We have drafted strategies to query and curate relevant datasets, developed a preliminary analysis plan, and await data deployment from VHA data stewards.

Conclusions

We believe this will be the first VHA-wide evaluation of patient encounter trends on IM services to examine potential training experiences for medical students. This will increase understanding of the critical role VHA has in developing the nations’ healthcare workforce, and how patterns of opportunities for clinical education may be distributed over time, informing decisions about rotation schedules to maximize students’ abilities to interact with, learn from, and serve our nation’s veterans

Background

The Accreditation Council for Graduate Medical Education (ACGME) mandates an 80-hour weekly work limit for residents.¹ In contrast, decisions regarding undergraduate medical education (UME) are strongly influenced locally, with individual institutions setting academic policy for students. These differences in oversight reflect fundamental differences in residents’ and students’ roles in patient care, power, and responsibility. Considering rotation schedules, internal medicine (IM) clerkship directors have discussed the relative value of weekend vs weekday duty during inpatient rotations, a scheduling topic of interest to students as well, though these conversations are limited by a lack of knowledge regarding admission patterns. Addressing this information gap would inform policy decisions.

The Veterans Health Administration (VHA) is uniquely positioned to address questions about UME clinical experiences nationwide: annually, over 118,000 students representing 97% of US medical schools train at VHA facilities.^2,3 We aim to compare the number and variety of patient encounter opportunities presenting during inpatient VHA IM rotations on weekdays versus weekends to inform policy decisions for UME rotation schedules.

Innovation

The VHA Corporate Data Warehouse will be queried for all admissions, diagnoses, and length of stay on inpatient IM services at the 420 VHA hospitals affiliated with US medical schools from 2016-2026. We will aggregate case data for day of week, floor, hospital, and Veteran Integrated Service Network (VISN), and determine number of admissions by weekday (Monday-Friday) and weekend (Saturday-Sunday). Weekday vs. weekend admission data will be compared using generalized mixed effects models for clustered longitudinal data. Heterogeneity across hospitals and VISNs will be explored to examine unique regional trends.

Results

We have drafted strategies to query and curate relevant datasets, developed a preliminary analysis plan, and await data deployment from VHA data stewards.

Conclusions

We believe this will be the first VHA-wide evaluation of patient encounter trends on IM services to examine potential training experiences for medical students. This will increase understanding of the critical role VHA has in developing the nations’ healthcare workforce, and how patterns of opportunities for clinical education may be distributed over time, informing decisions about rotation schedules to maximize students’ abilities to interact with, learn from, and serve our nation’s veterans

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.