Article

Key clinical point: Smoking worsened disease activity and health-related quality of life at 1 year in patients with rheumatoid arthritis (RA), with effects being persistent at 3 years and early smoking cessation vs. continued smoking being associated with improved disease activity.

Major finding: At 1 year, current smokers vs. non-smokers were at a higher risk for a swollen joint number above the median (odds ratio [OR] 1.7; P = .001) and 36-Item Short-Form Health Survey physical (OR 1.5; P = .006) and mental (OR 1.4; P = .03) scores below the median, with effects being persistent at 3 years. Patients who stopped vs. continued smoking within 1 year reported a lower swollen joint number (P = .002).

Study details: Findings are from a population-based case-control study including 1531 patients with newly diagnosed RA who were followed-up for 3 years, of which 376 patients were current smokers.

Disclosures: This study was supported by grants from the Swedish Medical Research Council and other sources. The authors declared no conflicts of interest.

Source: Alfredsson L et al. Influence of smoking on disease activity and quality of life in patients with rheumatoid arthritis: Results from a Swedish case-control study with longitudinal follow-up. Arthritis Care Res (Hoboken). 2022 (Sep 23). Doi: 10.1002/acr.25026

Key clinical point: Smoking worsened disease activity and health-related quality of life at 1 year in patients with rheumatoid arthritis (RA), with effects being persistent at 3 years and early smoking cessation vs. continued smoking being associated with improved disease activity.

Major finding: At 1 year, current smokers vs. non-smokers were at a higher risk for a swollen joint number above the median (odds ratio [OR] 1.7; P = .001) and 36-Item Short-Form Health Survey physical (OR 1.5; P = .006) and mental (OR 1.4; P = .03) scores below the median, with effects being persistent at 3 years. Patients who stopped vs. continued smoking within 1 year reported a lower swollen joint number (P = .002).

Study details: Findings are from a population-based case-control study including 1531 patients with newly diagnosed RA who were followed-up for 3 years, of which 376 patients were current smokers.

Disclosures: This study was supported by grants from the Swedish Medical Research Council and other sources. The authors declared no conflicts of interest.

Source: Alfredsson L et al. Influence of smoking on disease activity and quality of life in patients with rheumatoid arthritis: Results from a Swedish case-control study with longitudinal follow-up. Arthritis Care Res (Hoboken). 2022 (Sep 23). Doi: 10.1002/acr.25026

Key clinical point: Smoking worsened disease activity and health-related quality of life at 1 year in patients with rheumatoid arthritis (RA), with effects being persistent at 3 years and early smoking cessation vs. continued smoking being associated with improved disease activity.

Major finding: At 1 year, current smokers vs. non-smokers were at a higher risk for a swollen joint number above the median (odds ratio [OR] 1.7; P = .001) and 36-Item Short-Form Health Survey physical (OR 1.5; P = .006) and mental (OR 1.4; P = .03) scores below the median, with effects being persistent at 3 years. Patients who stopped vs. continued smoking within 1 year reported a lower swollen joint number (P = .002).

Study details: Findings are from a population-based case-control study including 1531 patients with newly diagnosed RA who were followed-up for 3 years, of which 376 patients were current smokers.

Disclosures: This study was supported by grants from the Swedish Medical Research Council and other sources. The authors declared no conflicts of interest.

Source: Alfredsson L et al. Influence of smoking on disease activity and quality of life in patients with rheumatoid arthritis: Results from a Swedish case-control study with longitudinal follow-up. Arthritis Care Res (Hoboken). 2022 (Sep 23). Doi: 10.1002/acr.25026

Key clinical point: Failure to initiate methotrexate within 3 months and discontinue glucocorticoids within 6 months during early disease management were associated with difficult-to-treat rheumatoid arthritis (D2T-RA).

Major finding: A significantly lower proportion of patients with D2T-RA had adequate methotrexate treatment duration vs. those with non-D2T-RA (70.8% v. 85.5%; P = .022). Additionally, a significantly higher proportion of patients with D2T-RA vs non-D2T-RA continued glucocorticoids beyond 6 months (70.8% vs 33.8%; P < .001), with a delay of <3 months vs >12 months in methotrexate treatment (odds ratio [OR] 0.3; P = .031) and failure to discontinue glucocorticoids (OR 4.6; P < .001) being significantly associated with D2T-RA.

Study details: Findings are from a retrospective cohort study including 48 patients with D2T-RA and 145 patients with non-D2T-RA.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Giollo A et al. Early characterisation of difficult-to-treat rheumatoid arthritis by suboptimal initial management A multicentre cohort study. Rheumatology (Oxford). 2022 (Oct 3). Doi: 10.1093/rheumatology/keac563

Key clinical point: Failure to initiate methotrexate within 3 months and discontinue glucocorticoids within 6 months during early disease management were associated with difficult-to-treat rheumatoid arthritis (D2T-RA).

Major finding: A significantly lower proportion of patients with D2T-RA had adequate methotrexate treatment duration vs. those with non-D2T-RA (70.8% v. 85.5%; P = .022). Additionally, a significantly higher proportion of patients with D2T-RA vs non-D2T-RA continued glucocorticoids beyond 6 months (70.8% vs 33.8%; P < .001), with a delay of <3 months vs >12 months in methotrexate treatment (odds ratio [OR] 0.3; P = .031) and failure to discontinue glucocorticoids (OR 4.6; P < .001) being significantly associated with D2T-RA.

Study details: Findings are from a retrospective cohort study including 48 patients with D2T-RA and 145 patients with non-D2T-RA.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Giollo A et al. Early characterisation of difficult-to-treat rheumatoid arthritis by suboptimal initial management A multicentre cohort study. Rheumatology (Oxford). 2022 (Oct 3). Doi: 10.1093/rheumatology/keac563

Key clinical point: Failure to initiate methotrexate within 3 months and discontinue glucocorticoids within 6 months during early disease management were associated with difficult-to-treat rheumatoid arthritis (D2T-RA).

Major finding: A significantly lower proportion of patients with D2T-RA had adequate methotrexate treatment duration vs. those with non-D2T-RA (70.8% v. 85.5%; P = .022). Additionally, a significantly higher proportion of patients with D2T-RA vs non-D2T-RA continued glucocorticoids beyond 6 months (70.8% vs 33.8%; P < .001), with a delay of <3 months vs >12 months in methotrexate treatment (odds ratio [OR] 0.3; P = .031) and failure to discontinue glucocorticoids (OR 4.6; P < .001) being significantly associated with D2T-RA.

Study details: Findings are from a retrospective cohort study including 48 patients with D2T-RA and 145 patients with non-D2T-RA.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Giollo A et al. Early characterisation of difficult-to-treat rheumatoid arthritis by suboptimal initial management A multicentre cohort study. Rheumatology (Oxford). 2022 (Oct 3). Doi: 10.1093/rheumatology/keac563

Key clinical point: Patients with rheumatoid arthritis (RA) treated with Janus kinase (JAK) vs tumor necrosis factor (TNF) inhibitors were at a higher risk for venous thromboembolism (VTE), particularly pulmonary embolism.

Major finding: Patients treated with JAK vs TNF inhibitors were at a 73% higher risk for VTE (adjusted hazard ratio [aHR] 1.73; 95% CI 1.24-2.42), with the higher risk appearing to be confined to pulmonary embolism (aHR 3.21; 95% CI 2.11-4.88) rather than deep vein thrombosis.

Study details: Findings are from a prospective, register-based, active comparator study including 85,722 patients with RA, of which 27,610 patients initiated biologic/targeted synthetic disease-modifying antirheumatic drugs and were matched with 91,207 healthy controls.

Disclosures: This study was funded by Swedish Research Council, the Swedish Heart Lung Foundation, and other sources. Karolinska Institutet has or has had research agreements with various sources for safety monitoring of biologics through ARTIS/Swedish Biologics Register.

Source: Molander V et al. Venous thromboembolism with JAK inhibitors and other immune-modulatory drugs: A Swedish comparative safety study among patients with rheumatoid arthritis. Ann Rheum Dis. 2022 (Sep 23). Doi: 10.1136/ard-2022-223050

Key clinical point: Patients with rheumatoid arthritis (RA) treated with Janus kinase (JAK) vs tumor necrosis factor (TNF) inhibitors were at a higher risk for venous thromboembolism (VTE), particularly pulmonary embolism.

Major finding: Patients treated with JAK vs TNF inhibitors were at a 73% higher risk for VTE (adjusted hazard ratio [aHR] 1.73; 95% CI 1.24-2.42), with the higher risk appearing to be confined to pulmonary embolism (aHR 3.21; 95% CI 2.11-4.88) rather than deep vein thrombosis.

Study details: Findings are from a prospective, register-based, active comparator study including 85,722 patients with RA, of which 27,610 patients initiated biologic/targeted synthetic disease-modifying antirheumatic drugs and were matched with 91,207 healthy controls.

Disclosures: This study was funded by Swedish Research Council, the Swedish Heart Lung Foundation, and other sources. Karolinska Institutet has or has had research agreements with various sources for safety monitoring of biologics through ARTIS/Swedish Biologics Register.

Source: Molander V et al. Venous thromboembolism with JAK inhibitors and other immune-modulatory drugs: A Swedish comparative safety study among patients with rheumatoid arthritis. Ann Rheum Dis. 2022 (Sep 23). Doi: 10.1136/ard-2022-223050

Key clinical point: Patients with rheumatoid arthritis (RA) treated with Janus kinase (JAK) vs tumor necrosis factor (TNF) inhibitors were at a higher risk for venous thromboembolism (VTE), particularly pulmonary embolism.

Major finding: Patients treated with JAK vs TNF inhibitors were at a 73% higher risk for VTE (adjusted hazard ratio [aHR] 1.73; 95% CI 1.24-2.42), with the higher risk appearing to be confined to pulmonary embolism (aHR 3.21; 95% CI 2.11-4.88) rather than deep vein thrombosis.

Study details: Findings are from a prospective, register-based, active comparator study including 85,722 patients with RA, of which 27,610 patients initiated biologic/targeted synthetic disease-modifying antirheumatic drugs and were matched with 91,207 healthy controls.

Disclosures: This study was funded by Swedish Research Council, the Swedish Heart Lung Foundation, and other sources. Karolinska Institutet has or has had research agreements with various sources for safety monitoring of biologics through ARTIS/Swedish Biologics Register.

Source: Molander V et al. Venous thromboembolism with JAK inhibitors and other immune-modulatory drugs: A Swedish comparative safety study among patients with rheumatoid arthritis. Ann Rheum Dis. 2022 (Sep 23). Doi: 10.1136/ard-2022-223050

Key clinical point: Withdrawal of methotrexate slightly worsened disease activity without affecting remission rates in patients with rheumatoid arthritis (RA) at target who were treated with the combination of biologic disease-modifying antirheumatic drugs (bDMARD)/targeted synthetic DMARD (tsDMARD) and methotrexate.

Major finding: Withdrawing methotrexate vs maintaining combination therapy increased the disease activity score of 28-joints by 0.20 (95% CI 0.09-0.32) and decreased the proportion of patients achieving low disease activity (risk ratio [RR] 0.88; 95% CI 0.80-0.97); however, the remission rates remained unaffected (RR 0.90; 95% CI 0.81-1.01).

Study details: Findings are from a systematic review and meta-analysis of six randomized controlled trials including 1430 patients with RA at target who were treated with bDMARD or tsDMARD+methotrexate combination therapy, of which 734 withdrew and 696 continued methotrexate.

Disclosures: This study was supported by West China Hospital, Sichuan University. The authors declared no conflicts of interest.

Source: Wang X et al. Withdrawal of MTX in rheumatoid arthritis patients on bDMARD/tsDMARD plus methotrexate at target: A systematic review and meta-analysis. Rheumatology (Oxford). 2022 (Sep 20). Doi: 10.1093/rheumatology/keac515

Key clinical point: Withdrawal of methotrexate slightly worsened disease activity without affecting remission rates in patients with rheumatoid arthritis (RA) at target who were treated with the combination of biologic disease-modifying antirheumatic drugs (bDMARD)/targeted synthetic DMARD (tsDMARD) and methotrexate.

Major finding: Withdrawing methotrexate vs maintaining combination therapy increased the disease activity score of 28-joints by 0.20 (95% CI 0.09-0.32) and decreased the proportion of patients achieving low disease activity (risk ratio [RR] 0.88; 95% CI 0.80-0.97); however, the remission rates remained unaffected (RR 0.90; 95% CI 0.81-1.01).

Study details: Findings are from a systematic review and meta-analysis of six randomized controlled trials including 1430 patients with RA at target who were treated with bDMARD or tsDMARD+methotrexate combination therapy, of which 734 withdrew and 696 continued methotrexate.

Disclosures: This study was supported by West China Hospital, Sichuan University. The authors declared no conflicts of interest.

Source: Wang X et al. Withdrawal of MTX in rheumatoid arthritis patients on bDMARD/tsDMARD plus methotrexate at target: A systematic review and meta-analysis. Rheumatology (Oxford). 2022 (Sep 20). Doi: 10.1093/rheumatology/keac515

Key clinical point: Withdrawal of methotrexate slightly worsened disease activity without affecting remission rates in patients with rheumatoid arthritis (RA) at target who were treated with the combination of biologic disease-modifying antirheumatic drugs (bDMARD)/targeted synthetic DMARD (tsDMARD) and methotrexate.

Major finding: Withdrawing methotrexate vs maintaining combination therapy increased the disease activity score of 28-joints by 0.20 (95% CI 0.09-0.32) and decreased the proportion of patients achieving low disease activity (risk ratio [RR] 0.88; 95% CI 0.80-0.97); however, the remission rates remained unaffected (RR 0.90; 95% CI 0.81-1.01).

Study details: Findings are from a systematic review and meta-analysis of six randomized controlled trials including 1430 patients with RA at target who were treated with bDMARD or tsDMARD+methotrexate combination therapy, of which 734 withdrew and 696 continued methotrexate.

Disclosures: This study was supported by West China Hospital, Sichuan University. The authors declared no conflicts of interest.

Source: Wang X et al. Withdrawal of MTX in rheumatoid arthritis patients on bDMARD/tsDMARD plus methotrexate at target: A systematic review and meta-analysis. Rheumatology (Oxford). 2022 (Sep 20). Doi: 10.1093/rheumatology/keac515

Key clinical point: Ultrasound-detected subclinical inflammation of tendons and joints was better controlled in patients with rheumatoid arthritis (RA) in clinical remission who received the combination therapy of conventional synthetic and biologic disease-modifying antirheumatic drugs (csDMARD+bDMARD) vs csDMARD or bDMARD monotherapy.

Major finding: Grey-scale tenosynovitis (P = .025) and power Doppler (PD) tenosynovitis (P = .047) were better controlled with csDMARD+bDMARD than with csDMARD alone. csDMARD+bDMARD was also associated with better treatment results for PD synovitis vs csDMARD (P = .01) or bDMARD (P = .02) alone.

Study details: Findings are from a longitudinal analysis of the STARTER study including 256 patients with RA in clinical remission who received csDMARD alone, bDMARD alone, or csDMARD+bDMARD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Parisi S et al. Relationship between the prevalence of subclinical tenosynovitis and treatment in patients with RA in clinical remission: STARTER study. Rheumatology (Oxford). 2022 (Sep 6). Doi: 10.1093/rheumatology/keac518

Key clinical point: Ultrasound-detected subclinical inflammation of tendons and joints was better controlled in patients with rheumatoid arthritis (RA) in clinical remission who received the combination therapy of conventional synthetic and biologic disease-modifying antirheumatic drugs (csDMARD+bDMARD) vs csDMARD or bDMARD monotherapy.

Major finding: Grey-scale tenosynovitis (P = .025) and power Doppler (PD) tenosynovitis (P = .047) were better controlled with csDMARD+bDMARD than with csDMARD alone. csDMARD+bDMARD was also associated with better treatment results for PD synovitis vs csDMARD (P = .01) or bDMARD (P = .02) alone.

Study details: Findings are from a longitudinal analysis of the STARTER study including 256 patients with RA in clinical remission who received csDMARD alone, bDMARD alone, or csDMARD+bDMARD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Parisi S et al. Relationship between the prevalence of subclinical tenosynovitis and treatment in patients with RA in clinical remission: STARTER study. Rheumatology (Oxford). 2022 (Sep 6). Doi: 10.1093/rheumatology/keac518

Key clinical point: Ultrasound-detected subclinical inflammation of tendons and joints was better controlled in patients with rheumatoid arthritis (RA) in clinical remission who received the combination therapy of conventional synthetic and biologic disease-modifying antirheumatic drugs (csDMARD+bDMARD) vs csDMARD or bDMARD monotherapy.

Major finding: Grey-scale tenosynovitis (P = .025) and power Doppler (PD) tenosynovitis (P = .047) were better controlled with csDMARD+bDMARD than with csDMARD alone. csDMARD+bDMARD was also associated with better treatment results for PD synovitis vs csDMARD (P = .01) or bDMARD (P = .02) alone.

Study details: Findings are from a longitudinal analysis of the STARTER study including 256 patients with RA in clinical remission who received csDMARD alone, bDMARD alone, or csDMARD+bDMARD.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Parisi S et al. Relationship between the prevalence of subclinical tenosynovitis and treatment in patients with RA in clinical remission: STARTER study. Rheumatology (Oxford). 2022 (Sep 6). Doi: 10.1093/rheumatology/keac518

Key clinical point: Patients with rheumatoid arthritis (RA), including those across different phenotypic subgroups, were at an increased risk for severe COVID-19 compared with patients without RA, with a pronounced association being observed in patients with RA-associated interstitial lung disease (RA-ILD).

Major finding: Risk for severe COVID-19 was significantly higher in patients with RA vs. those without RA (adjusted hazard ratio [aHR], 1.75; P < .0001). Risk was persistent among the sub-group of patients who were seropositive (aHR, 1.97; P < .0001) or had erosive disease (aHR, 1.93; P < .0001) and most prominent among patients with RA-ILD (aHR, 2.50; P < .0001).

Study details: Findings are from a retrospective study of 582 patients with RA and 2,875 matched comparators without RA, all of whom had COVID-19.

Disclosures: This study did not receive any funding. Some authors reported receiving research support, consulting fees, and/or grants unrelated to this study from various sources.

Source: Figueroa-Parra G et al. Risk of severe COVID-19 outcomes associated with rheumatoid arthritis and phenotypic subgroups: A retrospective, comparative, multicentre cohort study. Lancet Rheumatol. 2022 (Sep 13). Doi: 10.1016/S2665-9913(22)00227-2.

Key clinical point: Patients with rheumatoid arthritis (RA), including those across different phenotypic subgroups, were at an increased risk for severe COVID-19 compared with patients without RA, with a pronounced association being observed in patients with RA-associated interstitial lung disease (RA-ILD).

Major finding: Risk for severe COVID-19 was significantly higher in patients with RA vs. those without RA (adjusted hazard ratio [aHR], 1.75; P < .0001). Risk was persistent among the sub-group of patients who were seropositive (aHR, 1.97; P < .0001) or had erosive disease (aHR, 1.93; P < .0001) and most prominent among patients with RA-ILD (aHR, 2.50; P < .0001).

Study details: Findings are from a retrospective study of 582 patients with RA and 2,875 matched comparators without RA, all of whom had COVID-19.

Disclosures: This study did not receive any funding. Some authors reported receiving research support, consulting fees, and/or grants unrelated to this study from various sources.

Source: Figueroa-Parra G et al. Risk of severe COVID-19 outcomes associated with rheumatoid arthritis and phenotypic subgroups: A retrospective, comparative, multicentre cohort study. Lancet Rheumatol. 2022 (Sep 13). Doi: 10.1016/S2665-9913(22)00227-2.

Key clinical point: Patients with rheumatoid arthritis (RA), including those across different phenotypic subgroups, were at an increased risk for severe COVID-19 compared with patients without RA, with a pronounced association being observed in patients with RA-associated interstitial lung disease (RA-ILD).

Major finding: Risk for severe COVID-19 was significantly higher in patients with RA vs. those without RA (adjusted hazard ratio [aHR], 1.75; P < .0001). Risk was persistent among the sub-group of patients who were seropositive (aHR, 1.97; P < .0001) or had erosive disease (aHR, 1.93; P < .0001) and most prominent among patients with RA-ILD (aHR, 2.50; P < .0001).

Study details: Findings are from a retrospective study of 582 patients with RA and 2,875 matched comparators without RA, all of whom had COVID-19.

Disclosures: This study did not receive any funding. Some authors reported receiving research support, consulting fees, and/or grants unrelated to this study from various sources.

Source: Figueroa-Parra G et al. Risk of severe COVID-19 outcomes associated with rheumatoid arthritis and phenotypic subgroups: A retrospective, comparative, multicentre cohort study. Lancet Rheumatol. 2022 (Sep 13). Doi: 10.1016/S2665-9913(22)00227-2.

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

For years, the US Department of Veterans Affairs (VA) has painstakingly labored to track, research, and address veteran suicide. Their exceptional work was dealt an unwarranted blow a month ago with the publication of an incomplete report entitled Operation Deep Dive (OpDD). The $3.9 million study from America’s Warrior Partnership (AWP) examined death data of former service members in 8 states between 2014 and 2018. The interim report criticized the VA for minimizing the extent of veteran suicide, asserting, “former service members take their own lives each year at a rate approximately 2.4 times greater than previously reported by the VA.”

The sensational results were accepted at face value and immediately garnered negative nationwide headlines, with lawmakers, media outlets, and veterans rushing to impugn the VA. Senate Committee on Veterans’ Affairs Ranking Republican Member Jerry Moran of Kansas opined, “The disparity between the numbers of veteran suicides reported by the VA and [OpDD] is concerning. We need an honest assessment of the scope of the problem.” A U.S. Medicine headline stated “VA undercounted thousands of veteran suicides. [OpDD] posited daily suicide rate is 240% higher.” Fox News declared, “Veterans committing suicide at rate 2 times higher than VA data show: study,” as did Military Times, “Veterans suicide rate may be double federal estimates, study suggests.”

Disturbingly, those who echoed AWP’s claims got the story backward. It’s AWP, not VA, whose suicide data and conclusions are faulty.

For starters, the VA data encompasses veterans across all 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. In contrast, AWP inferred national veteran suicide figures based on partial, skewed data. As delineated by researchers in an in-press Military Medicine letter to the Editor, 7 of the 8 states sampled (Alabama, Florida, Maine, Massachusetts, Michigan, Minnesota, Montana, and Oregon) had suicide rates above the national average for the years under investigation. This factor alone overinflates AWP’s purported suicide numbers.

Additionally, AWP altered the definition of “taking one’s life” and then misapplied that designation. Conventionally, the term refers to suicide, but AWP used it to also include nonnatural deaths assessed by coroners and medical examiners as accidental or undetermined. Two examples of this self-injury mortality (SIM) are opioid overdoses and single-driver car crash deaths. AWP added suicides and SIMs to derive a total number of veterans who took their life and falsely contrasted that aggregate against the VA count of suicides. That’s like comparing the whole category of fruit to the subcategory of apples.

AWP should be applauded for drawing attention to and accounting for accidental and undetermined deaths. However, the standard protocol is to consider SIMs distinctly from suicides. Among the many reasons for precise labeling is so that grieving family members aren’t mistakenly informed that their loved one died by suicide. VA conveys the rate of veteran overdose deaths in separate reports, for example, the Veteran Drug Overdose Mortality, 2010-2019 publication. Those numbers were ignored in AWP’s calculations.

AWP was neglectful in another way. The second phase of the project—a deep examination of community-level factors preceding suicides and nonnatural deaths—began in 2019. This information was collected and analyzed through sociocultural death investigation (SDI) interviews of 3 to 4 family members, friends, and colleagues of the deceased. SDIs consisted of 19 factors, such as history of the veteran’s mental health problems, social connectedness, finances, group memberships, and access to firearms. However, the interim report omitted the preliminary analysis of these factors, which AWP stated would be made available this year.

OpDD conclusions were so unfounded that AWP’s analytic research partner, the University of Alabama, distanced itself from the interim report. “We were not consulted on the released figures,” Dr. Karl Hamner, the University of Alabama principal investigator on the study, told me. “We did not make any conclusions and we don’t endorse the reported findings about national rates or numbers per day. Nor did we make any statements about the VA’s data.”

As it happens, the VA’s 2022 National Veteran Suicide Prevention Annual Report was issued the same week as the OpDD report. VA found that veteran suicides decreased by 9.7% over the last 2 years, nearly twice the decrease for nonveterans. Yet, in a contemporaneous hearing of the House Committee on Veterans’ Affairs, AWP’s President and CEO Jim Lorraine testified that the progress preventing veteran suicide was “a disgrace” and “a failure.” He misattributed that it was VA (not AWP) that “must be more open and transparent about their data.”

Unsupported denigration of the VA tarnishes its reputation, undermining veterans’ trust in the health care system and increasing barriers to seeking needed services. More broadly, it fortifies those forces who wish to redirect allocations away from VA and towards non-VA veterans’ entities like AWP. The media and other stakeholders must take a lesson about getting the story straight before reflexively amplifying false accusations about the VA. Veterans deserve better.

Psychiatrists have a long tradition of supporting LGBTQAI+ (lesbian, gay, bisexual, transgender, queer/questioning, asexual, intersex, and others) persons. In professional and public settings, we are educators, role models, and advocates for self-expression and personal empowerment. By better educating ourselves on the topic of gender and its variations, we can become champions of gender-affirming care.

Sex vs gender

A person’s sex is assigned at birth based on their physiological characteristics, including their genitalia and chromosome composition. Male, female, and intersex are a few recognized sexes. Gender or gender identity describe one’s innermost perception of self as a man, a woman, a variation of both, or neither, that may not always be visible to others. When sex and gender identity align, this is known as cisgender.¹

Gender identity

Gender identity is best described as a spectrum rather than a binary. Terms that fall under a gender binary include man, woman, trans man, and trans woman. A nonbinary gender identity is one outside the traditional binary of men or women. Being transgender simply means having a gender identity different than the sex assigned at birth. This includes persons whose gender identities cross the gender spectrum, such as trans men or trans women, and those who fall anywhere outside or in between genders. In this way, nonbinary persons are transgender.¹

The nonbinary spectrum

The term nonbinary encompasses many gender-nonconforming identities, such as agender, bigender, demigender, genderfluid, genderqueer, intergender, or pangender. Agender people have little connection to gender. Bigender individuals identify as 2 separate genders. Demigender persons feel a partial connection to a gender. Genderfluid individuals have a gender experience that is fluid and can change over time. Genderqueer people have a gender identity that falls in between or outside the binary. Intergender people have a gender identity between genders or identify as a combination of genders. Pangender people identify with a combination of genders. Note that patients may use some of these terms interchangeably or ascribe to them different meanings.² As the language around gender continues to evolve, psychiatrists should ask patients from a place of nonjudgmental curiosity what gender terms they use, how they define them, and what their gender means to them.

Gender expression and transitioning

Transitioning is what a transgender person does to align their gender identity and expression.³ Gender expression is the external manifestation of gender, including names, pronouns, clothing, haircuts, behaviors, voice, body characteristics, and more.¹ Transgender individuals can transition using a combination of social (name, pronouns, dress), legal (changing sex on legal documents, name change), or medical (surgeries, hormone therapies, puberty blockade) means. Transitions often help ease gender dysphoria, which is the clinically significant distress a person experiences when their sex assigned at birth does not align with their gender identity.³ Note that not all transgender persons choose to change their gender expression, and not all transgender individuals experience gender dysphoria. In this case, the proper medical term is gender incongruence, which is simply when someone’s gender identity does not align with their sex assigned at birth.⁴

Names and pronouns

For many transgender persons, names and pronouns are an important part of their gender transition and expression.² Most of us have gotten into the habit of assuming pronouns because of socially established gender roles. This assumes that a person’s physical appearance matches their gender identity, which is not always the case.¹ To be more affirming, psychiatrists and other health care professionals should try to break the habit of assuming pronouns. Often, an easy way to learn someone’s pronouns is to introduce yourself with yours. For example, “I am Dr. Agapoff. I use they/them/theirs pronouns. It is nice to meet you.” This creates a safe and open space for the other person to share their gender identity if they choose.

Why it’s important

One does not have to be a gender specialist to deliver gender-affirming care. As psychiatrists, having a basic understanding of the differences between sex, gender identity, and gender expression can help us build rapport and support our patients who are transgender. Based on the many kinds of gender identity and expression, judging someone’s gender based solely upon physical appearance is misguided at best and harmful at worst. Even people who are cisgender have many kinds of gender expression. For this reason, psychiatrists should approach gender with the same openness and curiosity as sexual orientation or other important considerations of emotional and physical health. Gender-informed care starts with us.

Psychiatrists have a long tradition of supporting LGBTQAI+ (lesbian, gay, bisexual, transgender, queer/questioning, asexual, intersex, and others) persons. In professional and public settings, we are educators, role models, and advocates for self-expression and personal empowerment. By better educating ourselves on the topic of gender and its variations, we can become champions of gender-affirming care.

Sex vs gender

A person’s sex is assigned at birth based on their physiological characteristics, including their genitalia and chromosome composition. Male, female, and intersex are a few recognized sexes. Gender or gender identity describe one’s innermost perception of self as a man, a woman, a variation of both, or neither, that may not always be visible to others. When sex and gender identity align, this is known as cisgender.¹

Gender identity

Gender identity is best described as a spectrum rather than a binary. Terms that fall under a gender binary include man, woman, trans man, and trans woman. A nonbinary gender identity is one outside the traditional binary of men or women. Being transgender simply means having a gender identity different than the sex assigned at birth. This includes persons whose gender identities cross the gender spectrum, such as trans men or trans women, and those who fall anywhere outside or in between genders. In this way, nonbinary persons are transgender.¹

The nonbinary spectrum

The term nonbinary encompasses many gender-nonconforming identities, such as agender, bigender, demigender, genderfluid, genderqueer, intergender, or pangender. Agender people have little connection to gender. Bigender individuals identify as 2 separate genders. Demigender persons feel a partial connection to a gender. Genderfluid individuals have a gender experience that is fluid and can change over time. Genderqueer people have a gender identity that falls in between or outside the binary. Intergender people have a gender identity between genders or identify as a combination of genders. Pangender people identify with a combination of genders. Note that patients may use some of these terms interchangeably or ascribe to them different meanings.² As the language around gender continues to evolve, psychiatrists should ask patients from a place of nonjudgmental curiosity what gender terms they use, how they define them, and what their gender means to them.

Gender expression and transitioning

Transitioning is what a transgender person does to align their gender identity and expression.³ Gender expression is the external manifestation of gender, including names, pronouns, clothing, haircuts, behaviors, voice, body characteristics, and more.¹ Transgender individuals can transition using a combination of social (name, pronouns, dress), legal (changing sex on legal documents, name change), or medical (surgeries, hormone therapies, puberty blockade) means. Transitions often help ease gender dysphoria, which is the clinically significant distress a person experiences when their sex assigned at birth does not align with their gender identity.³ Note that not all transgender persons choose to change their gender expression, and not all transgender individuals experience gender dysphoria. In this case, the proper medical term is gender incongruence, which is simply when someone’s gender identity does not align with their sex assigned at birth.⁴

Names and pronouns

For many transgender persons, names and pronouns are an important part of their gender transition and expression.² Most of us have gotten into the habit of assuming pronouns because of socially established gender roles. This assumes that a person’s physical appearance matches their gender identity, which is not always the case.¹ To be more affirming, psychiatrists and other health care professionals should try to break the habit of assuming pronouns. Often, an easy way to learn someone’s pronouns is to introduce yourself with yours. For example, “I am Dr. Agapoff. I use they/them/theirs pronouns. It is nice to meet you.” This creates a safe and open space for the other person to share their gender identity if they choose.

Why it’s important

One does not have to be a gender specialist to deliver gender-affirming care. As psychiatrists, having a basic understanding of the differences between sex, gender identity, and gender expression can help us build rapport and support our patients who are transgender. Based on the many kinds of gender identity and expression, judging someone’s gender based solely upon physical appearance is misguided at best and harmful at worst. Even people who are cisgender have many kinds of gender expression. For this reason, psychiatrists should approach gender with the same openness and curiosity as sexual orientation or other important considerations of emotional and physical health. Gender-informed care starts with us.

Psychiatrists have a long tradition of supporting LGBTQAI+ (lesbian, gay, bisexual, transgender, queer/questioning, asexual, intersex, and others) persons. In professional and public settings, we are educators, role models, and advocates for self-expression and personal empowerment. By better educating ourselves on the topic of gender and its variations, we can become champions of gender-affirming care.

Sex vs gender

A person’s sex is assigned at birth based on their physiological characteristics, including their genitalia and chromosome composition. Male, female, and intersex are a few recognized sexes. Gender or gender identity describe one’s innermost perception of self as a man, a woman, a variation of both, or neither, that may not always be visible to others. When sex and gender identity align, this is known as cisgender.¹

Gender identity

Gender identity is best described as a spectrum rather than a binary. Terms that fall under a gender binary include man, woman, trans man, and trans woman. A nonbinary gender identity is one outside the traditional binary of men or women. Being transgender simply means having a gender identity different than the sex assigned at birth. This includes persons whose gender identities cross the gender spectrum, such as trans men or trans women, and those who fall anywhere outside or in between genders. In this way, nonbinary persons are transgender.¹

The nonbinary spectrum

The term nonbinary encompasses many gender-nonconforming identities, such as agender, bigender, demigender, genderfluid, genderqueer, intergender, or pangender. Agender people have little connection to gender. Bigender individuals identify as 2 separate genders. Demigender persons feel a partial connection to a gender. Genderfluid individuals have a gender experience that is fluid and can change over time. Genderqueer people have a gender identity that falls in between or outside the binary. Intergender people have a gender identity between genders or identify as a combination of genders. Pangender people identify with a combination of genders. Note that patients may use some of these terms interchangeably or ascribe to them different meanings.² As the language around gender continues to evolve, psychiatrists should ask patients from a place of nonjudgmental curiosity what gender terms they use, how they define them, and what their gender means to them.

Gender expression and transitioning

Transitioning is what a transgender person does to align their gender identity and expression.³ Gender expression is the external manifestation of gender, including names, pronouns, clothing, haircuts, behaviors, voice, body characteristics, and more.¹ Transgender individuals can transition using a combination of social (name, pronouns, dress), legal (changing sex on legal documents, name change), or medical (surgeries, hormone therapies, puberty blockade) means. Transitions often help ease gender dysphoria, which is the clinically significant distress a person experiences when their sex assigned at birth does not align with their gender identity.³ Note that not all transgender persons choose to change their gender expression, and not all transgender individuals experience gender dysphoria. In this case, the proper medical term is gender incongruence, which is simply when someone’s gender identity does not align with their sex assigned at birth.⁴

Names and pronouns

For many transgender persons, names and pronouns are an important part of their gender transition and expression.² Most of us have gotten into the habit of assuming pronouns because of socially established gender roles. This assumes that a person’s physical appearance matches their gender identity, which is not always the case.¹ To be more affirming, psychiatrists and other health care professionals should try to break the habit of assuming pronouns. Often, an easy way to learn someone’s pronouns is to introduce yourself with yours. For example, “I am Dr. Agapoff. I use they/them/theirs pronouns. It is nice to meet you.” This creates a safe and open space for the other person to share their gender identity if they choose.

Why it’s important

One does not have to be a gender specialist to deliver gender-affirming care. As psychiatrists, having a basic understanding of the differences between sex, gender identity, and gender expression can help us build rapport and support our patients who are transgender. Based on the many kinds of gender identity and expression, judging someone’s gender based solely upon physical appearance is misguided at best and harmful at worst. Even people who are cisgender have many kinds of gender expression. For this reason, psychiatrists should approach gender with the same openness and curiosity as sexual orientation or other important considerations of emotional and physical health. Gender-informed care starts with us.

Sarah Sheffield, a nurse practitioner at a Veterans Affairs clinic in Eugene, Oregon, had a problem. Her patients — mostly in their 70s and beyond — couldn’t read computer screens. It’s not an unusual problem for older people, which is why you might think Oracle Cerner, the developers of the agency’s new digital health record system, would have anticipated it.

But they didn’t.

Federal law requires government resources to be accessible to patients with disabilities. But patients can’t easily enlarge the text. “They all learned to get strong reading glasses and magnifying glasses,” said Sheffield, who retired in early October.

The difficulties are everyday reminders of a dire reality for patients in the VA system. More than a million patients are blind or have low vision. They rely on software to access prescriptions or send messages to their doctors. But often the technology fails them. Either the screens don’t allow users to zoom in on the text, or screen-reader software that translates text to speech isn’t compatible.

“None of the systems are accessible” to these patients, said Donald Overton, executive director of the Blinded Veterans Association.

Patients often struggle even to log into websites or enter basic information needed to check in for hospital visits, Overton said: “We find our community stops trying, checks out, and disengages. They become dependent on other individuals; they give up independence.”

Now, the developing VA medical record system, already bloated by outsize costs, has been delayed until June 2023. So far, the project has threatened to exacerbate those issues.

While users in general have been affected by numerous incidents of downtime, delayed care, and missing information, barriers to access are particularly acute for blind and low-vision users — whether patients or workers within the health system. At least one Oregon-based employee has been offered aid — a helper assigned to read and click buttons — to navigate the system.

Over 1,000 Section 508 complaints are in a backlog to be assessed, or assigned to Oracle Cerner to fix, Veterans Affairs spokesperson Terrence Hayes confirmed. That section is part of federal law guaranteeing people with disabilities access to government technology.

Hayes said the problems described by these complaints don’t prevent employees and patients with disabilities from using the system. The complaints — 469 of which have been assigned to Oracle Cerner to fix, he said — mean that users’ disabilities make it more difficult, to the point of requiring mitigation.

The project is under new management with big promises. North Kansas City, Missouri-based developer Cerner, which originally landed the VA contract, was recently taken over by database technology giant Oracle, which plans to overhaul the software, company executive Mike Sicilia said during a September Senate hearing. “We intend to rewrite” the system, he said. “We have found nothing that can’t be addressed in relatively short order.”

But that will happen under continued scrutiny. Rep. Mark Takano (D-Calif.), chair of the House Veterans Affairs Committee, said his panel would continue to oversee the department’s compliance with accessibility standards. “Whether they work for VA or receive health care and benefits, the needs of veterans must be addressed by companies that want to work with the VA,” he said.

Takano, along with fellow Democrats Sens. Bob Casey of Pennsylvania and Jon Tester of Montana, sent a letter Oct. 7 to VA Secretary Denis McDonough noting the significant gaps in the agency’s systems, and urging VA to engage with all disabled veterans, not merely those who are blind.

VA was alerted early and often that Cerner’s software posed problems for blind- and low-vision users, interviews and a review of records show. As early as 2015, when the Department of Defense and VA were exploring purchasing new systems, the National Federation of the Blind submitted letters to both departments, and Cerner, expressing concerns that the product would be unusable for clinicians and patients.

Alerts also came from inside VA. “We pointed out to Cerner that their system was really dependent on vision and that it was a major problem. The icons are really, really small,” said Dr. Art Wallace, a VA anesthesiologist who participated in one of the agency’s user groups to provide input for the eventual design of the system.

The Cerner system, he told the agency and KHN, is user-unfriendly. On the clinician side, it requires multiple high-resolution monitors to display a patient’s entire record, and VA facilities don’t always enjoy that wealth of equipment. “It would be very hard for visually impaired people, or normal people wearing bifocals, to use,” he concluded.

Before the software was rolled out, the system also failed a test with an employee working with a team at Oregon’s White City VA Medical Center devoted to helping blind patients develop skills and independence, said Carolyn Schwab, president of the American Federation of Government Employees Local 1042.

In the testing, the system didn’t work with adaptive equipment, like text-to-speech software, she said. Despite receiving these complaints about the system, VA and Cerner “implemented it anyway.” Recently, when a regional AFGE president asked VA why they used the software — despite the federal mandates — he received no response, Schwab said.

Some within the company also thought there would be struggles. Two former Cerner employees said the standard medical record system was getting long in the tooth when VA signed an agreement to purchase and customize the product.

Because it was built on old code, the software was difficult to patch when problems were discovered, the employees said. What’s more, according to the employees, Cerner took a doggedly incremental approach to fixing errors. If someone complained about a malfunctioning button on a page filled with other potholes, the company would fix just that button — not the whole page, the employees said.

VA spokesperson Hayes denied the claims, saying the developer and department try to address problems holistically. Cerner did not respond to multiple requests for comment.

Accessibility errors are as present in private sector medical record systems as public. Cerner patched up a bug with the Safari web browser’s rendering of its patient portal when the Massachusetts Institute of Technology’s student clinic threatened legal action, the former employees said. (“MIT Medical does not, as a general practice, discuss individual vendor contracts or services,” said spokesperson David Tytell.)

Legal threats — with hospital systems and medical record systems routinely facing lawsuits — are the most obvious symptom of a lack of accessibility within the U.S. health care system.

Deep inaccessibility plagues the burgeoning telehealth sector. A recent survey from the American Federation for the Blind found that 57% of respondents struggled to use providers’ proprietary telehealth platforms. Some resorted to FaceTime. Many said they were unable to log in or couldn’t read information transmitted through chat sidebars.

Existing federal regulations could, in theory, be used to enforce higher standards of accessibility in health technology. The Department of Health and Human Services Office for Civil Rights issued guidance during the pandemic on making telehealth technologies easier to use for patients with disabilities. And other agencies could start leaning on hospitals, because they are recipients of government dollars or federal vendors, to make sure their offerings work for such patients.

That might not happen. These regulations could prove toothless, advocates warn. While there are several laws on the books, the advocates argue that enforcement and tougher regulations have not been forthcoming. “The concern from stakeholders is: Are you going to slow-walk this again?” said Joe Nahra, director of government relations at Powers Law, a Washington, D.C., law firm.

Building in accessibility has historically benefited all users. Voice assistance technology was originally developed to help blind- and low-vision users before winning widespread popularity with gadgets like Siri and Alexa.

Disability advocates believe vendors often push technology ahead without properly considering the impact on the people who will rely on it. “In the rush to be the first one, they put accessibility on the back burner,” said Eve Hill, a disability rights attorney with Brown, Goldstein & Levy, a civil rights law firm.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Sarah Sheffield, a nurse practitioner at a Veterans Affairs clinic in Eugene, Oregon, had a problem. Her patients — mostly in their 70s and beyond — couldn’t read computer screens. It’s not an unusual problem for older people, which is why you might think Oracle Cerner, the developers of the agency’s new digital health record system, would have anticipated it.

But they didn’t.

Federal law requires government resources to be accessible to patients with disabilities. But patients can’t easily enlarge the text. “They all learned to get strong reading glasses and magnifying glasses,” said Sheffield, who retired in early October.

The difficulties are everyday reminders of a dire reality for patients in the VA system. More than a million patients are blind or have low vision. They rely on software to access prescriptions or send messages to their doctors. But often the technology fails them. Either the screens don’t allow users to zoom in on the text, or screen-reader software that translates text to speech isn’t compatible.

“None of the systems are accessible” to these patients, said Donald Overton, executive director of the Blinded Veterans Association.

Patients often struggle even to log into websites or enter basic information needed to check in for hospital visits, Overton said: “We find our community stops trying, checks out, and disengages. They become dependent on other individuals; they give up independence.”

Now, the developing VA medical record system, already bloated by outsize costs, has been delayed until June 2023. So far, the project has threatened to exacerbate those issues.

While users in general have been affected by numerous incidents of downtime, delayed care, and missing information, barriers to access are particularly acute for blind and low-vision users — whether patients or workers within the health system. At least one Oregon-based employee has been offered aid — a helper assigned to read and click buttons — to navigate the system.

Over 1,000 Section 508 complaints are in a backlog to be assessed, or assigned to Oracle Cerner to fix, Veterans Affairs spokesperson Terrence Hayes confirmed. That section is part of federal law guaranteeing people with disabilities access to government technology.

Hayes said the problems described by these complaints don’t prevent employees and patients with disabilities from using the system. The complaints — 469 of which have been assigned to Oracle Cerner to fix, he said — mean that users’ disabilities make it more difficult, to the point of requiring mitigation.

The project is under new management with big promises. North Kansas City, Missouri-based developer Cerner, which originally landed the VA contract, was recently taken over by database technology giant Oracle, which plans to overhaul the software, company executive Mike Sicilia said during a September Senate hearing. “We intend to rewrite” the system, he said. “We have found nothing that can’t be addressed in relatively short order.”

But that will happen under continued scrutiny. Rep. Mark Takano (D-Calif.), chair of the House Veterans Affairs Committee, said his panel would continue to oversee the department’s compliance with accessibility standards. “Whether they work for VA or receive health care and benefits, the needs of veterans must be addressed by companies that want to work with the VA,” he said.

Takano, along with fellow Democrats Sens. Bob Casey of Pennsylvania and Jon Tester of Montana, sent a letter Oct. 7 to VA Secretary Denis McDonough noting the significant gaps in the agency’s systems, and urging VA to engage with all disabled veterans, not merely those who are blind.

VA was alerted early and often that Cerner’s software posed problems for blind- and low-vision users, interviews and a review of records show. As early as 2015, when the Department of Defense and VA were exploring purchasing new systems, the National Federation of the Blind submitted letters to both departments, and Cerner, expressing concerns that the product would be unusable for clinicians and patients.

Alerts also came from inside VA. “We pointed out to Cerner that their system was really dependent on vision and that it was a major problem. The icons are really, really small,” said Dr. Art Wallace, a VA anesthesiologist who participated in one of the agency’s user groups to provide input for the eventual design of the system.

The Cerner system, he told the agency and KHN, is user-unfriendly. On the clinician side, it requires multiple high-resolution monitors to display a patient’s entire record, and VA facilities don’t always enjoy that wealth of equipment. “It would be very hard for visually impaired people, or normal people wearing bifocals, to use,” he concluded.

Before the software was rolled out, the system also failed a test with an employee working with a team at Oregon’s White City VA Medical Center devoted to helping blind patients develop skills and independence, said Carolyn Schwab, president of the American Federation of Government Employees Local 1042.

In the testing, the system didn’t work with adaptive equipment, like text-to-speech software, she said. Despite receiving these complaints about the system, VA and Cerner “implemented it anyway.” Recently, when a regional AFGE president asked VA why they used the software — despite the federal mandates — he received no response, Schwab said.

Some within the company also thought there would be struggles. Two former Cerner employees said the standard medical record system was getting long in the tooth when VA signed an agreement to purchase and customize the product.

Because it was built on old code, the software was difficult to patch when problems were discovered, the employees said. What’s more, according to the employees, Cerner took a doggedly incremental approach to fixing errors. If someone complained about a malfunctioning button on a page filled with other potholes, the company would fix just that button — not the whole page, the employees said.

VA spokesperson Hayes denied the claims, saying the developer and department try to address problems holistically. Cerner did not respond to multiple requests for comment.

Accessibility errors are as present in private sector medical record systems as public. Cerner patched up a bug with the Safari web browser’s rendering of its patient portal when the Massachusetts Institute of Technology’s student clinic threatened legal action, the former employees said. (“MIT Medical does not, as a general practice, discuss individual vendor contracts or services,” said spokesperson David Tytell.)

Legal threats — with hospital systems and medical record systems routinely facing lawsuits — are the most obvious symptom of a lack of accessibility within the U.S. health care system.

Deep inaccessibility plagues the burgeoning telehealth sector. A recent survey from the American Federation for the Blind found that 57% of respondents struggled to use providers’ proprietary telehealth platforms. Some resorted to FaceTime. Many said they were unable to log in or couldn’t read information transmitted through chat sidebars.

Existing federal regulations could, in theory, be used to enforce higher standards of accessibility in health technology. The Department of Health and Human Services Office for Civil Rights issued guidance during the pandemic on making telehealth technologies easier to use for patients with disabilities. And other agencies could start leaning on hospitals, because they are recipients of government dollars or federal vendors, to make sure their offerings work for such patients.

That might not happen. These regulations could prove toothless, advocates warn. While there are several laws on the books, the advocates argue that enforcement and tougher regulations have not been forthcoming. “The concern from stakeholders is: Are you going to slow-walk this again?” said Joe Nahra, director of government relations at Powers Law, a Washington, D.C., law firm.

Building in accessibility has historically benefited all users. Voice assistance technology was originally developed to help blind- and low-vision users before winning widespread popularity with gadgets like Siri and Alexa.

Disability advocates believe vendors often push technology ahead without properly considering the impact on the people who will rely on it. “In the rush to be the first one, they put accessibility on the back burner,” said Eve Hill, a disability rights attorney with Brown, Goldstein & Levy, a civil rights law firm.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Sarah Sheffield, a nurse practitioner at a Veterans Affairs clinic in Eugene, Oregon, had a problem. Her patients — mostly in their 70s and beyond — couldn’t read computer screens. It’s not an unusual problem for older people, which is why you might think Oracle Cerner, the developers of the agency’s new digital health record system, would have anticipated it.

But they didn’t.

Federal law requires government resources to be accessible to patients with disabilities. But patients can’t easily enlarge the text. “They all learned to get strong reading glasses and magnifying glasses,” said Sheffield, who retired in early October.

The difficulties are everyday reminders of a dire reality for patients in the VA system. More than a million patients are blind or have low vision. They rely on software to access prescriptions or send messages to their doctors. But often the technology fails them. Either the screens don’t allow users to zoom in on the text, or screen-reader software that translates text to speech isn’t compatible.

“None of the systems are accessible” to these patients, said Donald Overton, executive director of the Blinded Veterans Association.

Patients often struggle even to log into websites or enter basic information needed to check in for hospital visits, Overton said: “We find our community stops trying, checks out, and disengages. They become dependent on other individuals; they give up independence.”

Now, the developing VA medical record system, already bloated by outsize costs, has been delayed until June 2023. So far, the project has threatened to exacerbate those issues.

While users in general have been affected by numerous incidents of downtime, delayed care, and missing information, barriers to access are particularly acute for blind and low-vision users — whether patients or workers within the health system. At least one Oregon-based employee has been offered aid — a helper assigned to read and click buttons — to navigate the system.

Over 1,000 Section 508 complaints are in a backlog to be assessed, or assigned to Oracle Cerner to fix, Veterans Affairs spokesperson Terrence Hayes confirmed. That section is part of federal law guaranteeing people with disabilities access to government technology.

Hayes said the problems described by these complaints don’t prevent employees and patients with disabilities from using the system. The complaints — 469 of which have been assigned to Oracle Cerner to fix, he said — mean that users’ disabilities make it more difficult, to the point of requiring mitigation.

The project is under new management with big promises. North Kansas City, Missouri-based developer Cerner, which originally landed the VA contract, was recently taken over by database technology giant Oracle, which plans to overhaul the software, company executive Mike Sicilia said during a September Senate hearing. “We intend to rewrite” the system, he said. “We have found nothing that can’t be addressed in relatively short order.”

But that will happen under continued scrutiny. Rep. Mark Takano (D-Calif.), chair of the House Veterans Affairs Committee, said his panel would continue to oversee the department’s compliance with accessibility standards. “Whether they work for VA or receive health care and benefits, the needs of veterans must be addressed by companies that want to work with the VA,” he said.

Takano, along with fellow Democrats Sens. Bob Casey of Pennsylvania and Jon Tester of Montana, sent a letter Oct. 7 to VA Secretary Denis McDonough noting the significant gaps in the agency’s systems, and urging VA to engage with all disabled veterans, not merely those who are blind.

VA was alerted early and often that Cerner’s software posed problems for blind- and low-vision users, interviews and a review of records show. As early as 2015, when the Department of Defense and VA were exploring purchasing new systems, the National Federation of the Blind submitted letters to both departments, and Cerner, expressing concerns that the product would be unusable for clinicians and patients.

Alerts also came from inside VA. “We pointed out to Cerner that their system was really dependent on vision and that it was a major problem. The icons are really, really small,” said Dr. Art Wallace, a VA anesthesiologist who participated in one of the agency’s user groups to provide input for the eventual design of the system.

The Cerner system, he told the agency and KHN, is user-unfriendly. On the clinician side, it requires multiple high-resolution monitors to display a patient’s entire record, and VA facilities don’t always enjoy that wealth of equipment. “It would be very hard for visually impaired people, or normal people wearing bifocals, to use,” he concluded.

Before the software was rolled out, the system also failed a test with an employee working with a team at Oregon’s White City VA Medical Center devoted to helping blind patients develop skills and independence, said Carolyn Schwab, president of the American Federation of Government Employees Local 1042.

In the testing, the system didn’t work with adaptive equipment, like text-to-speech software, she said. Despite receiving these complaints about the system, VA and Cerner “implemented it anyway.” Recently, when a regional AFGE president asked VA why they used the software — despite the federal mandates — he received no response, Schwab said.

Some within the company also thought there would be struggles. Two former Cerner employees said the standard medical record system was getting long in the tooth when VA signed an agreement to purchase and customize the product.

Because it was built on old code, the software was difficult to patch when problems were discovered, the employees said. What’s more, according to the employees, Cerner took a doggedly incremental approach to fixing errors. If someone complained about a malfunctioning button on a page filled with other potholes, the company would fix just that button — not the whole page, the employees said.

VA spokesperson Hayes denied the claims, saying the developer and department try to address problems holistically. Cerner did not respond to multiple requests for comment.

Accessibility errors are as present in private sector medical record systems as public. Cerner patched up a bug with the Safari web browser’s rendering of its patient portal when the Massachusetts Institute of Technology’s student clinic threatened legal action, the former employees said. (“MIT Medical does not, as a general practice, discuss individual vendor contracts or services,” said spokesperson David Tytell.)

Legal threats — with hospital systems and medical record systems routinely facing lawsuits — are the most obvious symptom of a lack of accessibility within the U.S. health care system.

Deep inaccessibility plagues the burgeoning telehealth sector. A recent survey from the American Federation for the Blind found that 57% of respondents struggled to use providers’ proprietary telehealth platforms. Some resorted to FaceTime. Many said they were unable to log in or couldn’t read information transmitted through chat sidebars.

Existing federal regulations could, in theory, be used to enforce higher standards of accessibility in health technology. The Department of Health and Human Services Office for Civil Rights issued guidance during the pandemic on making telehealth technologies easier to use for patients with disabilities. And other agencies could start leaning on hospitals, because they are recipients of government dollars or federal vendors, to make sure their offerings work for such patients.

That might not happen. These regulations could prove toothless, advocates warn. While there are several laws on the books, the advocates argue that enforcement and tougher regulations have not been forthcoming. “The concern from stakeholders is: Are you going to slow-walk this again?” said Joe Nahra, director of government relations at Powers Law, a Washington, D.C., law firm.

Building in accessibility has historically benefited all users. Voice assistance technology was originally developed to help blind- and low-vision users before winning widespread popularity with gadgets like Siri and Alexa.

Disability advocates believe vendors often push technology ahead without properly considering the impact on the people who will rely on it. “In the rush to be the first one, they put accessibility on the back burner,” said Eve Hill, a disability rights attorney with Brown, Goldstein & Levy, a civil rights law firm.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Key clinical point: Pregnancy-related cardiometabolic condition of any type was associated with almost a 3-fold higher risk for severe cardiovascular outcomes in the perinatal and postnatal periods, with preeclampsia being associated with a 7-fold higher risk for severe cardiovascular outcomes.

Major finding: Risk for severe cardiovascular outcomes was higher in women with vs without pregnancy-related cardiometabolic conditions (adjusted odds ratio [aOR] 3.1; 95% CI 2.7-3.5), with the risk being most prominent for severe preeclampsia (aOR 7.0; 95% CI 5.7-8.6).

Study details: This was a post hoc analysis of the deidentified administrative data of 74,510 women who had at least one delivery during the observation period.

Disclosures: This study did not declare any specific source of funding. The authors did not declare any conflicts of interest.

Source: Marschner S et al. Pregnancy-related cardiovascular conditions and outcomes in a United States Medicaid population. Heart. 2022;108(19):1524-1529 (Sep 12). Doi: 10.1136/heartjnl-2021-320684

Key clinical point: Pregnancy-related cardiometabolic condition of any type was associated with almost a 3-fold higher risk for severe cardiovascular outcomes in the perinatal and postnatal periods, with preeclampsia being associated with a 7-fold higher risk for severe cardiovascular outcomes.

Major finding: Risk for severe cardiovascular outcomes was higher in women with vs without pregnancy-related cardiometabolic conditions (adjusted odds ratio [aOR] 3.1; 95% CI 2.7-3.5), with the risk being most prominent for severe preeclampsia (aOR 7.0; 95% CI 5.7-8.6).

Study details: This was a post hoc analysis of the deidentified administrative data of 74,510 women who had at least one delivery during the observation period.

Disclosures: This study did not declare any specific source of funding. The authors did not declare any conflicts of interest.

Source: Marschner S et al. Pregnancy-related cardiovascular conditions and outcomes in a United States Medicaid population. Heart. 2022;108(19):1524-1529 (Sep 12). Doi: 10.1136/heartjnl-2021-320684

Key clinical point: Pregnancy-related cardiometabolic condition of any type was associated with almost a 3-fold higher risk for severe cardiovascular outcomes in the perinatal and postnatal periods, with preeclampsia being associated with a 7-fold higher risk for severe cardiovascular outcomes.

Major finding: Risk for severe cardiovascular outcomes was higher in women with vs without pregnancy-related cardiometabolic conditions (adjusted odds ratio [aOR] 3.1; 95% CI 2.7-3.5), with the risk being most prominent for severe preeclampsia (aOR 7.0; 95% CI 5.7-8.6).

Study details: This was a post hoc analysis of the deidentified administrative data of 74,510 women who had at least one delivery during the observation period.

Disclosures: This study did not declare any specific source of funding. The authors did not declare any conflicts of interest.

Source: Marschner S et al. Pregnancy-related cardiovascular conditions and outcomes in a United States Medicaid population. Heart. 2022;108(19):1524-1529 (Sep 12). Doi: 10.1136/heartjnl-2021-320684