Federal Practitioner

TOPLINE:

Posttraumatic stress disorder (PTSD) among veterans living with HIV significantly increased the risk for AIDS and multiple comorbidities, particularly arthritis, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and multimorbidity — with the greatest impact seen in the first decade after diagnosis.

METHODOLOGY:

• Researchers conducted a prospective cohort study to assess whether PTSD is associated with increased risk for adverse clinical outcomes in veterans with HIV who received care at the Department of Veterans Affairs.
• They included 3206 veterans (97.4% men; median age at HIV diagnosis, 31.7 years; 42.1% with PTSD) who were deployed in Iraq and Afghanistan while serving in the military and initiated antiretroviral therapy before December 31, 2020.
• Participants were followed-up until December 2022, with censoring at death, the last health care visit, or study termination. The association between PTSD with morbidity and mortality, considering the number of deployments and levels of combat exposure were determined.

TAKEAWAY:

• PTSD significantly increased the overall risks for AIDS by 11% (adjusted hazard ratio [aHR], 1.11), CKD by 21% (aHR, 1.21), COPD by 46% (aHR, 1.46), multimorbidity by 49% (aHR, 1.49), CVD by 57% (aHR, 1.57), and arthritis by two folds (aHR, 1.95; P <.05 for all).
• Among veterans with a single deployment, those with PTSD had 92%, 87%, 80%, 53%, 44%, 32%, and 27% higher risks for asthma, CVD, arthritis, multimorbidity, COPD, liver disease, and AIDS, respectively, than those without PTSD.
• Veterans with PTSD and combat exposure had a lower risk for AIDS but higher risks for multimorbidity, asthma, CVD, and arthritis than those never diagnosed with PTSD and unexposed to combat.
• The associations of PTSD with mortality and morbidity appeared most pronounced in the first decade post-diagnosis, followed by a gradual decline in association strength; however, risks remained elevated.

IN PRACTICE:

“It is recommended that providers who work with VWH [veterans with HIV] consider adopting a trauma-informed model of HIV care and that providers screen veterans for PTSD, so that their unique trauma history can help guide medical decisions and treatment,” the authors wrote.

SOURCE:

This study was led by Kartavya J. Vyas, PhD, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta. It was published online in AIDS .

LIMITATIONS:

The data could not capture each individual’s true index trauma or the severity of their PTSD. Additionally, the study was limited by considerable loss to follow-up, potential uncontrolled confounding related to homelessness, and a lack of generalizability to veterans with HIV who were not receiving antiretroviral therapy.

DISCLOSURES:

The study did not receive any specific funding. Two authors reported receiving federal research support — one from the Emory Center for AIDS Research and the National Institute of Allergy and Infectious Diseases, and the other from the National Institutes of Health and the CDC — in addition to investigator-initiated grants and consulting fees from various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Posttraumatic stress disorder (PTSD) among veterans living with HIV significantly increased the risk for AIDS and multiple comorbidities, particularly arthritis, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and multimorbidity — with the greatest impact seen in the first decade after diagnosis.

METHODOLOGY:

• Researchers conducted a prospective cohort study to assess whether PTSD is associated with increased risk for adverse clinical outcomes in veterans with HIV who received care at the Department of Veterans Affairs.
• They included 3206 veterans (97.4% men; median age at HIV diagnosis, 31.7 years; 42.1% with PTSD) who were deployed in Iraq and Afghanistan while serving in the military and initiated antiretroviral therapy before December 31, 2020.
• Participants were followed-up until December 2022, with censoring at death, the last health care visit, or study termination. The association between PTSD with morbidity and mortality, considering the number of deployments and levels of combat exposure were determined.

TAKEAWAY:

• PTSD significantly increased the overall risks for AIDS by 11% (adjusted hazard ratio [aHR], 1.11), CKD by 21% (aHR, 1.21), COPD by 46% (aHR, 1.46), multimorbidity by 49% (aHR, 1.49), CVD by 57% (aHR, 1.57), and arthritis by two folds (aHR, 1.95; P <.05 for all).
• Among veterans with a single deployment, those with PTSD had 92%, 87%, 80%, 53%, 44%, 32%, and 27% higher risks for asthma, CVD, arthritis, multimorbidity, COPD, liver disease, and AIDS, respectively, than those without PTSD.
• Veterans with PTSD and combat exposure had a lower risk for AIDS but higher risks for multimorbidity, asthma, CVD, and arthritis than those never diagnosed with PTSD and unexposed to combat.
• The associations of PTSD with mortality and morbidity appeared most pronounced in the first decade post-diagnosis, followed by a gradual decline in association strength; however, risks remained elevated.

IN PRACTICE:

“It is recommended that providers who work with VWH [veterans with HIV] consider adopting a trauma-informed model of HIV care and that providers screen veterans for PTSD, so that their unique trauma history can help guide medical decisions and treatment,” the authors wrote.

SOURCE:

This study was led by Kartavya J. Vyas, PhD, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta. It was published online in AIDS .

LIMITATIONS:

The data could not capture each individual’s true index trauma or the severity of their PTSD. Additionally, the study was limited by considerable loss to follow-up, potential uncontrolled confounding related to homelessness, and a lack of generalizability to veterans with HIV who were not receiving antiretroviral therapy.

DISCLOSURES:

The study did not receive any specific funding. Two authors reported receiving federal research support — one from the Emory Center for AIDS Research and the National Institute of Allergy and Infectious Diseases, and the other from the National Institutes of Health and the CDC — in addition to investigator-initiated grants and consulting fees from various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Posttraumatic stress disorder (PTSD) among veterans living with HIV significantly increased the risk for AIDS and multiple comorbidities, particularly arthritis, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and multimorbidity — with the greatest impact seen in the first decade after diagnosis.

METHODOLOGY:

• Researchers conducted a prospective cohort study to assess whether PTSD is associated with increased risk for adverse clinical outcomes in veterans with HIV who received care at the Department of Veterans Affairs.
• They included 3206 veterans (97.4% men; median age at HIV diagnosis, 31.7 years; 42.1% with PTSD) who were deployed in Iraq and Afghanistan while serving in the military and initiated antiretroviral therapy before December 31, 2020.
• Participants were followed-up until December 2022, with censoring at death, the last health care visit, or study termination. The association between PTSD with morbidity and mortality, considering the number of deployments and levels of combat exposure were determined.

TAKEAWAY:

• PTSD significantly increased the overall risks for AIDS by 11% (adjusted hazard ratio [aHR], 1.11), CKD by 21% (aHR, 1.21), COPD by 46% (aHR, 1.46), multimorbidity by 49% (aHR, 1.49), CVD by 57% (aHR, 1.57), and arthritis by two folds (aHR, 1.95; P <.05 for all).
• Among veterans with a single deployment, those with PTSD had 92%, 87%, 80%, 53%, 44%, 32%, and 27% higher risks for asthma, CVD, arthritis, multimorbidity, COPD, liver disease, and AIDS, respectively, than those without PTSD.
• Veterans with PTSD and combat exposure had a lower risk for AIDS but higher risks for multimorbidity, asthma, CVD, and arthritis than those never diagnosed with PTSD and unexposed to combat.
• The associations of PTSD with mortality and morbidity appeared most pronounced in the first decade post-diagnosis, followed by a gradual decline in association strength; however, risks remained elevated.

IN PRACTICE:

“It is recommended that providers who work with VWH [veterans with HIV] consider adopting a trauma-informed model of HIV care and that providers screen veterans for PTSD, so that their unique trauma history can help guide medical decisions and treatment,” the authors wrote.

SOURCE:

This study was led by Kartavya J. Vyas, PhD, Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta. It was published online in AIDS .

LIMITATIONS:

The data could not capture each individual’s true index trauma or the severity of their PTSD. Additionally, the study was limited by considerable loss to follow-up, potential uncontrolled confounding related to homelessness, and a lack of generalizability to veterans with HIV who were not receiving antiretroviral therapy.

DISCLOSURES:

The study did not receive any specific funding. Two authors reported receiving federal research support — one from the Emory Center for AIDS Research and the National Institute of Allergy and Infectious Diseases, and the other from the National Institutes of Health and the CDC — in addition to investigator-initiated grants and consulting fees from various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

The US House Appropriations Committee approved a $453 billion budget to fund the US Department of Veterans (VA), military construction, and other programs in 2026 by a 36-27 vote. The bill includes $34 billion proposed for community care programs, an increase of > 50% from 2025 community care funding levels.

The discretionary funding would also send $2.5 billion to the VA electronic health records modernization program. Mandatory spending includes $53 billion for the Toxic Exposures Fund, which supports benefits and health care costs associated with the PACT Act.

Although VA budget bills are typically bipartisan in nature, this bill passed by a much narrower margin than is typical. Rep. Debbie Wasserman Schultz (D-FL), ranking member of the Military Construction, Veterans Affairs and Related Agencies Appropriations Subcommittee, said the bill “diverts far too many resources away from the vital, VA-based care that veterans consistently tell us they want, and it pushes them into pricier, subpar corporate hospitals.” 

Committee Democrats offered dozens of amendments. All amendments were rejected except for a modification that would block staff reductions at the Veterans Crisis Line and other VA suicide prevention programs.

The bill now moves to the full House of Representatives for consideration. House leaders have not yet announced when that vote will take place; the House is in recess the week of June 16, 2025. 

The committee also released the Fiscal Year 2026 Military Construction, Veterans Affairs, and Related Agencies Bill, which would spend > $83 million, a 22% increase over the 2025.

The US House Appropriations Committee approved a $453 billion budget to fund the US Department of Veterans (VA), military construction, and other programs in 2026 by a 36-27 vote. The bill includes $34 billion proposed for community care programs, an increase of > 50% from 2025 community care funding levels.

The discretionary funding would also send $2.5 billion to the VA electronic health records modernization program. Mandatory spending includes $53 billion for the Toxic Exposures Fund, which supports benefits and health care costs associated with the PACT Act.

Although VA budget bills are typically bipartisan in nature, this bill passed by a much narrower margin than is typical. Rep. Debbie Wasserman Schultz (D-FL), ranking member of the Military Construction, Veterans Affairs and Related Agencies Appropriations Subcommittee, said the bill “diverts far too many resources away from the vital, VA-based care that veterans consistently tell us they want, and it pushes them into pricier, subpar corporate hospitals.” 

Committee Democrats offered dozens of amendments. All amendments were rejected except for a modification that would block staff reductions at the Veterans Crisis Line and other VA suicide prevention programs.

The bill now moves to the full House of Representatives for consideration. House leaders have not yet announced when that vote will take place; the House is in recess the week of June 16, 2025. 

The committee also released the Fiscal Year 2026 Military Construction, Veterans Affairs, and Related Agencies Bill, which would spend > $83 million, a 22% increase over the 2025.

The US House Appropriations Committee approved a $453 billion budget to fund the US Department of Veterans (VA), military construction, and other programs in 2026 by a 36-27 vote. The bill includes $34 billion proposed for community care programs, an increase of > 50% from 2025 community care funding levels.

The discretionary funding would also send $2.5 billion to the VA electronic health records modernization program. Mandatory spending includes $53 billion for the Toxic Exposures Fund, which supports benefits and health care costs associated with the PACT Act.

Although VA budget bills are typically bipartisan in nature, this bill passed by a much narrower margin than is typical. Rep. Debbie Wasserman Schultz (D-FL), ranking member of the Military Construction, Veterans Affairs and Related Agencies Appropriations Subcommittee, said the bill “diverts far too many resources away from the vital, VA-based care that veterans consistently tell us they want, and it pushes them into pricier, subpar corporate hospitals.” 

Committee Democrats offered dozens of amendments. All amendments were rejected except for a modification that would block staff reductions at the Veterans Crisis Line and other VA suicide prevention programs.

The bill now moves to the full House of Representatives for consideration. House leaders have not yet announced when that vote will take place; the House is in recess the week of June 16, 2025. 

The committee also released the Fiscal Year 2026 Military Construction, Veterans Affairs, and Related Agencies Bill, which would spend > $83 million, a 22% increase over the 2025.

Oritavancin and dalbavancin are long acting lipoglycopeptides indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI).^1,2 Largely due to their long half-lives, prolonged tissue concentrations at sites of infection, tolerability, and minimal requirement for therapeutic drug monitoring, these agents are attractive options in outpatient settings.^3,4 A 1- or 2-dose treatment of oritavancin and dalbavancin may be sufficient for conditions traditionally treated with outpatient parenteral antimicrobial therapy (OPAT) via peripherally inserted central catheter (PICC).

Limited research supports the use of dalbavancin and oritavancin for bone and joint infections, infective endocarditis, and bloodstream infections (BSIs). However, the US Food and Drug Administration has approved an indication for the treatment of ABSSSI.^3-9 Dosing for these off-label indications varies but typically consists of an initial intravenous (IV) dose (1000 mg, 1200 mg, or 1500 mg), with a subsequent dose 1 to 2 weeks later or administered once weekly.^6-10

Due in part to the recent availability of oritavancin and dalbavancin relative to the publication of practice guidelines, their appropriate place in therapy continues to evolve based on emerging literature.^11,12 One potential barrier of use for these medications is their cost. Based on the number of doses administered, the 2022 estimated total acquisition cost of therapy for oritavancin and dalbavancin was $1014 to $4397 and $3046 to $7150, respectively (eAppendix). Despite the high acquisition costs, these agents do not require the placement of an indwelling central line, can be administered in outpatient settings, and require minimal therapeutic dose monitoring compared to vancomycin.^13-15 This medication use evaluation (MUE) compared the total cost of treatment with oritavancin and dalbavancin vs therapies traditionally used for OPAT or prolonged IV inpatient therapy.

METHODS

This retrospective MUE was conducted at the Boise Veterans Affairs Medical Center (BVAMC), a level 2 facility with an extensive rural catchment area. BVAMC provides many OPAT services, including medications, supplies, and dressing changes after initial clinic or inpatient education. Contracted vendors may also assist with at-home nursing care using supplies provided by the BVAMC. Cases were identified using an internal database of OPAT patients and those who received oritavancin or dalbavancin between September 1, 2017, and November 1, 2022. Patients aged ≥ 18 years who received ≥ 1 dose of oritavancin or dalbavancin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were included. Comparator treatments consisting of ≥ 1 week of vancomycin or daptomycin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were identified through review of OPAT and Infectious Diseases service consults during the same timeframe. Patients were excluded if any antibiotic was prescribed by a non- VA clinician, if medications were not provided by OPAT, or if chart review did not identify an ABSSSI, osteomyelitis/ joint infection, or BSI diagnosis.

Electronic medical record review was conducted using a standardized data collection form (eAppendix). Data collected included demographics, infectious diagnosis, treatment administered, administration procedures and related visits and treatment locations, outcomes including clinical failure, adverse events (AEs), and hospital readmission.

Clinical failure was defined as readmission or death due to worsening infection or readmission secondary to a documented potential AE to the evaluated antibiotics within 90 days after initiation. Clinical failures excluded readmissions not associated with infection including comorbidities or elective procedures. AEs included new onset renal failure (serum creatinine ≥ 0.5 mg/dL), neutropenia (neutrophils ≤ 500), thrombocytopenia (platelets < 100,000), eosinophilia (> 15% eosinophils), or creatine phosphokinase > 10 times the upper limit of normal, and Clostridioides difficile (C. difficile) infection. Line complications included thrombophlebitis, local inflammation, or infection requiring line replacement (eAppendix).

A cost-minimization approach was used to assess the total cost of treatment.¹⁶ Patients who received oritavancin or dalbavancin were matched with patients that received vancomycin and daptomycin for the same indication and about 1 month of initiation through the randomization function in Microsoft Excel. This accounted for changes in personnel, nonformulary drug approvals, cost, and changes in practice during the pandemic. Costs were calculated using a decision tree as a base model (Figure 1). In this model, each treatment dyad was assessed for the presence or absence of clinical failure, adverse event (medication and line complications), and treatment setting endpoints. Cost estimates were tabulated for each patient that received treatment using published VA data, literature, pharmacoeconomist guidance, or best faith effort based on workflow. ^17-20 All cost estimates were based on 2022 figures or adjusted for inflation if obtained prior to 2022. Secondary endpoints of this analysis included estimated total cost of medication acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home-health services.

This evaluation was classified by the BVAMC Medication Use Evaluation research determination subcommittee as a quality improvement project and was considered exempt from VA Human Subjects Research requirements based on the VA Policy Handbook guideline 1058.05.

RESULTS

The study identified 44 patients who received dalbavancin or oritavancin between September 1, 2017, and October 31, 2022. Thirty-nine patients were included in the analysis: 24 received oritavancin and 15 received dalbavancin and were matched by indication to 10 patients who received vancomycin and 8 patients who received daptomycin. Three patients could not be matched by indication of ABSSSI (Figure 2). Most patients were male, aged > 65 years, and were treated for osteomyelitis (Table 1). No patients were treated for infective endocarditis. A myriad of concomitant antibiotics were used to treat patients and culture results indicated that most infections treated with oritavancin and dalbavancin were polymicrobial.

The mean total cost of therapy per patient receiving oritavancin, dalbavancin, vancomycin, and daptomycin was $35,630, $59,612, $73,333, and $73,708, respectively (Figure 3). When stratified by indication, 27 patients (69%) in the oritavancin/dalbavancin group were treated for osteomyelitis/ joint infections (16 oritavancin, 11 dalbavancin), 9 patients (23%) were treated for BSI (6 oritavancin, 3 dalbavancin), and 3 patients (8%) were treated for ABSSSI (2 oritavancin, 1 dalbavancin). The mean cost per patient for osteomyelitis/joint infections with oritavancin, dalbavancin, vancomycin, and daptomycin was $34,678, $54,224, $87,488, and $85,044, respectively. The mean cost per patient for BSI for oritavancin, dalbavancin, vancomycin, and daptomycin was $35,048, $75,349, $40,305, and $68,068, respectively. The mean cost per patient for ABSSSI for oritavancin and dalbavancin was $44,771 and $71,672.51.

Estimated total drug cost represents the cost of drug acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home health services. The mean cost per patient of drug-related therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2203, $5924, $3637, and $7146, respectively (Table 2).

The mean cost per patient for osteomyelitis therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2375, $6775, $4164, $8152, respectively. The mean cost of per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $1737, $3475, $2409, and $1016, respectively. The mean cost per patient for oritavancin and dalbavancin for ABSSSI treatment, was $1553 and $3910, respectively.

Setting-related costs include expenses from inpatient admissions and postdischarge stays at community living centers (CLCs), skilled nursing facilities (SNFs), or rehabilitation facilities (RFs) for the duration of antimicrobial therapy. The mean setting-related therapy cost for osteomyelitis treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $27,852, $17,815, $83,324, and $72,856, respectively. The mean setting-related therapy cost per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $33,310, $60,668, $37,734, and $67,074, respectively. The mean setting-related therapy cost per patient for ABSSSI treatment for oritavancin and dalbavancin was $43,218 and $67,762.00, respectively.

Six of 39 patients (15%) had clinical failure: 2 patients with oritavancin and 4 patients with dalbavancin. Four patients were readmitted for worsening infection and 2 for AEs. One patient (13%) in the daptomycin group had clinical failure due to readmission for worsening infection. There was no clinical failure with vancomycin. The costs associated with clinical failure per patient for oritavancin, dalbavancin, vancomycin, and daptomycin were $2925, $23,972, $0, and $3601, respectively (Table 3).

Thirty-eight patients (97%) who received oritavancin or dalbavancin had difficulty adhering to vancomycin or daptomycin OPAT. Oritavancin or dalbavancin was used in 10 patients (26%) who lacked support at home and 15 patients (38%) who had either a contraindication or previous failure with other antimicrobials, which were the most common explanations.

DISCUSSION

Long-acting lipoglycopeptides represent a potential alternative to home IV therapy that can avoid prolonged IV access with traditional OPAT. This offers significant advantages, allowing patients to be discharged from the hospital early, especially in rural areas with little OPAT infrastructure or those with logistic challenges. In this analysis, treatment with oritavancin for osteomyelitis, BSI, or ABSSSI, yielded an estimated cost savings of about $37,000 per patient, compared to treatment of matched indications with vancomycin and daptomycin. For every patient treated with dalbavancin for osteomyelitis, BSI, or ABSSSI, the cost savings was about $13,000 per patient, compared to treatment of matched indications for daptomycin and vancomycin. The estimated cost savings per patient for oritavancin was similar to previously published projections ($30,500 to $55,831).¹⁵

Cost savings were primarily driven by setting-related costs. The greatest contrast between the oritavancin and dalbavancin group compared to the vancomycin and daptomycin group was the length of stay in a postdischarge CLC, SNF, or RF setting. This analysis estimated that for every patient treated with oritavancin for osteomyelitis, the setting-related cost savings per patient was about $55,000 compared with vancomycin, and about $45,000 per patient compared with daptomycin. Furthermore, the estimated setting-related cost savings for osteomyelitis treatment with dalbavancin was about $65,000 compared with vancomycin and about $55,000 compared with daptomycin.

Clinical failure occurred with greater frequency in the oritavancin and dalbavancin groups (15%), compared with the vancomycin (0%) and daptomycin (13%) groups. Although the clinical failure rates in patients with osteomyelitis treated with oritavancin and dalbavancin compared with daptomycin were like those in previously published research (10%-30%), the rates of clinical failure for vancomycin in this analysis were lower than those in the oritavancin and dalbavancin group.^8,21,22 The discrepancy in clinical failure rates between this analysis and previous research is likely due to selection bias. Based on the percentages of clinical failure found in the analysis, it is not surprising to note that the total clinical failure-related cost per patient was higher for oritavancin and dalbavancin compared to vancomycin, but similar between oritavancin and daptomycin.

This analysis also found that 15% of patients in the oritavancin and dalbavancin group experienced an AE compared to 10% of patients in the vancomycin group and none in the daptomycin group. In the oritavancin and dalbavancin group, the 2 most common AEs were infusion-related reactions and C. difficile colitis. Although infusion related reactions are easier to correspond to oritavancin and dalbavancin, it becomes difficult to definitively attribute the occurrence of C. difficile to these drugs as many patients were receiving concomitant antibiotics. Although not a primary or secondary objective, the rate of IV-line AEs were more prevalent in the vancomycin (10%), and daptomycin (13%) groups, compared to none in the oritavancin and dalbavancin group. This finding was expected; oritavancin and dalbavancin do not require a central IV line for administration.

Pharmacoeconomic literature continues to emerge with long-acting lipoglycopeptides. A 2024 Italian retrospective single-center analysis of 62 patients reported mean cost reductions > €3200 per patient (> $3400) given dalbavancin compared with the standard of care for ABSSSI or more deep-seeded infections such as osteomyelitis.²³ A 2023 Spanish observational multicenter analysis of 124 patients with infective endocarditis demonstrated high efficacy, safety and cost-effectiveness with dalbavancin vs conventional treatments, with a mean savings of > €5548 per patient (> $6200).²⁴ An analysis of the implementation of a dalbavancin order pathway for ABSSSI to avert inpatient admissions at 11 US emergency departments found a mean cost savings of $5133 per patient and $1211 per hospitalization day avoided, compared with inpatient usual care.²⁵

Conversely, a multicenter, retrospective study of 209 patients in a community-based health care system failed to show a financial benefit for dalbavancin use when compared to standard of care for ABSSSI with higher readmission rates.²⁶ Turco et al also reported increased cost results for 64 patients who received dalbavancin vs standard of care for ABSSSI.²⁷ These discordant findings in ABSSSI studies may be impacted by the authors' patient selection choices and cost assumptions, especially with significantly cheaper oral alternatives. More data are needed to best identify the optimal therapeutic use for the long-acting lipoglycopeptides.

Limitations

The most significant limitation in this analysis was selection bias: 38 of 39 patients (97%) who received dalbavancin or oritavancin had a documented reason that described why OPAT therapy with traditional medications would not be optimal, including logistics, AEs, or clinical failures. Most patients treated with vancomycin and daptomycin were admitted into a SNF, RF, or CLC for the remainder of their treatment, allowing for closer monitoring and care compared to patients treated with oritavancin and dalbavancin, but at a greater cost. For patients sent to a community based SNF or RF, laboratory data were not available unless internally drawn or documented in the electronic medical record.

Additionally, not all cost data were available from VA sources; some were applied from literature, pharmacoeconomist, or best faith effort based on workflow. The cost data from third party contractors providing OPAT services to some BVAMC patients during the time frame of this analysis were not available. Due to its small sample size, outliers had the potential to affect averages reported and accuracy of the cost analysis. Emerging evidence suggests that daptomycin doses higher than the manufacturer-recommended regimen may be required for select indications, a factor that could affect cost, AEs, and efficacy outcomes.²⁸ The acquisition cost of oritavancin and dalbavancin may vary by institution (ie, VA contract prices vs non- VA contract prices) and change over time. A current assessment of cost is needed to best visualize institutional benefit.

Finally, while the patient demographic of this MUE was highly representative of the demographic treated at the BVAMC (males aged >65 years), it may not be applicable to external patient populations. This analysis evaluated off-label indications for these medications. Consequently, this analysis would likely not be applicable to non-VA institution, as third-party payers (eg, insurance) are unlikely to cover medications for off-label indications.

CONCLUSIONS

This study found cost savings associated with the use of oritavancin and dalbavancin compared with vancomycin and daptomycin, particularly for the treatment of osteomyelitis. As safety and efficacy data continues to emerge, the use of long-acting lipoglycopeptides appears to be an increasingly attractive alternative option compared to traditional outpatient antimicrobial therapy, depending on the structure of the program. Larger, multicenter cost-effectiveness studies are needed to further establish the impact of these novel agents.

Oritavancin and dalbavancin are long acting lipoglycopeptides indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI).^1,2 Largely due to their long half-lives, prolonged tissue concentrations at sites of infection, tolerability, and minimal requirement for therapeutic drug monitoring, these agents are attractive options in outpatient settings.^3,4 A 1- or 2-dose treatment of oritavancin and dalbavancin may be sufficient for conditions traditionally treated with outpatient parenteral antimicrobial therapy (OPAT) via peripherally inserted central catheter (PICC).

Limited research supports the use of dalbavancin and oritavancin for bone and joint infections, infective endocarditis, and bloodstream infections (BSIs). However, the US Food and Drug Administration has approved an indication for the treatment of ABSSSI.^3-9 Dosing for these off-label indications varies but typically consists of an initial intravenous (IV) dose (1000 mg, 1200 mg, or 1500 mg), with a subsequent dose 1 to 2 weeks later or administered once weekly.^6-10

Due in part to the recent availability of oritavancin and dalbavancin relative to the publication of practice guidelines, their appropriate place in therapy continues to evolve based on emerging literature.^11,12 One potential barrier of use for these medications is their cost. Based on the number of doses administered, the 2022 estimated total acquisition cost of therapy for oritavancin and dalbavancin was $1014 to $4397 and $3046 to $7150, respectively (eAppendix). Despite the high acquisition costs, these agents do not require the placement of an indwelling central line, can be administered in outpatient settings, and require minimal therapeutic dose monitoring compared to vancomycin.^13-15 This medication use evaluation (MUE) compared the total cost of treatment with oritavancin and dalbavancin vs therapies traditionally used for OPAT or prolonged IV inpatient therapy.

METHODS

This retrospective MUE was conducted at the Boise Veterans Affairs Medical Center (BVAMC), a level 2 facility with an extensive rural catchment area. BVAMC provides many OPAT services, including medications, supplies, and dressing changes after initial clinic or inpatient education. Contracted vendors may also assist with at-home nursing care using supplies provided by the BVAMC. Cases were identified using an internal database of OPAT patients and those who received oritavancin or dalbavancin between September 1, 2017, and November 1, 2022. Patients aged ≥ 18 years who received ≥ 1 dose of oritavancin or dalbavancin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were included. Comparator treatments consisting of ≥ 1 week of vancomycin or daptomycin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were identified through review of OPAT and Infectious Diseases service consults during the same timeframe. Patients were excluded if any antibiotic was prescribed by a non- VA clinician, if medications were not provided by OPAT, or if chart review did not identify an ABSSSI, osteomyelitis/ joint infection, or BSI diagnosis.

Electronic medical record review was conducted using a standardized data collection form (eAppendix). Data collected included demographics, infectious diagnosis, treatment administered, administration procedures and related visits and treatment locations, outcomes including clinical failure, adverse events (AEs), and hospital readmission.

Clinical failure was defined as readmission or death due to worsening infection or readmission secondary to a documented potential AE to the evaluated antibiotics within 90 days after initiation. Clinical failures excluded readmissions not associated with infection including comorbidities or elective procedures. AEs included new onset renal failure (serum creatinine ≥ 0.5 mg/dL), neutropenia (neutrophils ≤ 500), thrombocytopenia (platelets < 100,000), eosinophilia (> 15% eosinophils), or creatine phosphokinase > 10 times the upper limit of normal, and Clostridioides difficile (C. difficile) infection. Line complications included thrombophlebitis, local inflammation, or infection requiring line replacement (eAppendix).

A cost-minimization approach was used to assess the total cost of treatment.¹⁶ Patients who received oritavancin or dalbavancin were matched with patients that received vancomycin and daptomycin for the same indication and about 1 month of initiation through the randomization function in Microsoft Excel. This accounted for changes in personnel, nonformulary drug approvals, cost, and changes in practice during the pandemic. Costs were calculated using a decision tree as a base model (Figure 1). In this model, each treatment dyad was assessed for the presence or absence of clinical failure, adverse event (medication and line complications), and treatment setting endpoints. Cost estimates were tabulated for each patient that received treatment using published VA data, literature, pharmacoeconomist guidance, or best faith effort based on workflow. ^17-20 All cost estimates were based on 2022 figures or adjusted for inflation if obtained prior to 2022. Secondary endpoints of this analysis included estimated total cost of medication acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home-health services.

This evaluation was classified by the BVAMC Medication Use Evaluation research determination subcommittee as a quality improvement project and was considered exempt from VA Human Subjects Research requirements based on the VA Policy Handbook guideline 1058.05.

RESULTS

The study identified 44 patients who received dalbavancin or oritavancin between September 1, 2017, and October 31, 2022. Thirty-nine patients were included in the analysis: 24 received oritavancin and 15 received dalbavancin and were matched by indication to 10 patients who received vancomycin and 8 patients who received daptomycin. Three patients could not be matched by indication of ABSSSI (Figure 2). Most patients were male, aged > 65 years, and were treated for osteomyelitis (Table 1). No patients were treated for infective endocarditis. A myriad of concomitant antibiotics were used to treat patients and culture results indicated that most infections treated with oritavancin and dalbavancin were polymicrobial.

The mean total cost of therapy per patient receiving oritavancin, dalbavancin, vancomycin, and daptomycin was $35,630, $59,612, $73,333, and $73,708, respectively (Figure 3). When stratified by indication, 27 patients (69%) in the oritavancin/dalbavancin group were treated for osteomyelitis/ joint infections (16 oritavancin, 11 dalbavancin), 9 patients (23%) were treated for BSI (6 oritavancin, 3 dalbavancin), and 3 patients (8%) were treated for ABSSSI (2 oritavancin, 1 dalbavancin). The mean cost per patient for osteomyelitis/joint infections with oritavancin, dalbavancin, vancomycin, and daptomycin was $34,678, $54,224, $87,488, and $85,044, respectively. The mean cost per patient for BSI for oritavancin, dalbavancin, vancomycin, and daptomycin was $35,048, $75,349, $40,305, and $68,068, respectively. The mean cost per patient for ABSSSI for oritavancin and dalbavancin was $44,771 and $71,672.51.

Estimated total drug cost represents the cost of drug acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home health services. The mean cost per patient of drug-related therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2203, $5924, $3637, and $7146, respectively (Table 2).

The mean cost per patient for osteomyelitis therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2375, $6775, $4164, $8152, respectively. The mean cost of per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $1737, $3475, $2409, and $1016, respectively. The mean cost per patient for oritavancin and dalbavancin for ABSSSI treatment, was $1553 and $3910, respectively.

Setting-related costs include expenses from inpatient admissions and postdischarge stays at community living centers (CLCs), skilled nursing facilities (SNFs), or rehabilitation facilities (RFs) for the duration of antimicrobial therapy. The mean setting-related therapy cost for osteomyelitis treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $27,852, $17,815, $83,324, and $72,856, respectively. The mean setting-related therapy cost per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $33,310, $60,668, $37,734, and $67,074, respectively. The mean setting-related therapy cost per patient for ABSSSI treatment for oritavancin and dalbavancin was $43,218 and $67,762.00, respectively.

Six of 39 patients (15%) had clinical failure: 2 patients with oritavancin and 4 patients with dalbavancin. Four patients were readmitted for worsening infection and 2 for AEs. One patient (13%) in the daptomycin group had clinical failure due to readmission for worsening infection. There was no clinical failure with vancomycin. The costs associated with clinical failure per patient for oritavancin, dalbavancin, vancomycin, and daptomycin were $2925, $23,972, $0, and $3601, respectively (Table 3).

Thirty-eight patients (97%) who received oritavancin or dalbavancin had difficulty adhering to vancomycin or daptomycin OPAT. Oritavancin or dalbavancin was used in 10 patients (26%) who lacked support at home and 15 patients (38%) who had either a contraindication or previous failure with other antimicrobials, which were the most common explanations.

DISCUSSION

Long-acting lipoglycopeptides represent a potential alternative to home IV therapy that can avoid prolonged IV access with traditional OPAT. This offers significant advantages, allowing patients to be discharged from the hospital early, especially in rural areas with little OPAT infrastructure or those with logistic challenges. In this analysis, treatment with oritavancin for osteomyelitis, BSI, or ABSSSI, yielded an estimated cost savings of about $37,000 per patient, compared to treatment of matched indications with vancomycin and daptomycin. For every patient treated with dalbavancin for osteomyelitis, BSI, or ABSSSI, the cost savings was about $13,000 per patient, compared to treatment of matched indications for daptomycin and vancomycin. The estimated cost savings per patient for oritavancin was similar to previously published projections ($30,500 to $55,831).¹⁵

Cost savings were primarily driven by setting-related costs. The greatest contrast between the oritavancin and dalbavancin group compared to the vancomycin and daptomycin group was the length of stay in a postdischarge CLC, SNF, or RF setting. This analysis estimated that for every patient treated with oritavancin for osteomyelitis, the setting-related cost savings per patient was about $55,000 compared with vancomycin, and about $45,000 per patient compared with daptomycin. Furthermore, the estimated setting-related cost savings for osteomyelitis treatment with dalbavancin was about $65,000 compared with vancomycin and about $55,000 compared with daptomycin.

Clinical failure occurred with greater frequency in the oritavancin and dalbavancin groups (15%), compared with the vancomycin (0%) and daptomycin (13%) groups. Although the clinical failure rates in patients with osteomyelitis treated with oritavancin and dalbavancin compared with daptomycin were like those in previously published research (10%-30%), the rates of clinical failure for vancomycin in this analysis were lower than those in the oritavancin and dalbavancin group.^8,21,22 The discrepancy in clinical failure rates between this analysis and previous research is likely due to selection bias. Based on the percentages of clinical failure found in the analysis, it is not surprising to note that the total clinical failure-related cost per patient was higher for oritavancin and dalbavancin compared to vancomycin, but similar between oritavancin and daptomycin.

This analysis also found that 15% of patients in the oritavancin and dalbavancin group experienced an AE compared to 10% of patients in the vancomycin group and none in the daptomycin group. In the oritavancin and dalbavancin group, the 2 most common AEs were infusion-related reactions and C. difficile colitis. Although infusion related reactions are easier to correspond to oritavancin and dalbavancin, it becomes difficult to definitively attribute the occurrence of C. difficile to these drugs as many patients were receiving concomitant antibiotics. Although not a primary or secondary objective, the rate of IV-line AEs were more prevalent in the vancomycin (10%), and daptomycin (13%) groups, compared to none in the oritavancin and dalbavancin group. This finding was expected; oritavancin and dalbavancin do not require a central IV line for administration.

Pharmacoeconomic literature continues to emerge with long-acting lipoglycopeptides. A 2024 Italian retrospective single-center analysis of 62 patients reported mean cost reductions > €3200 per patient (> $3400) given dalbavancin compared with the standard of care for ABSSSI or more deep-seeded infections such as osteomyelitis.²³ A 2023 Spanish observational multicenter analysis of 124 patients with infective endocarditis demonstrated high efficacy, safety and cost-effectiveness with dalbavancin vs conventional treatments, with a mean savings of > €5548 per patient (> $6200).²⁴ An analysis of the implementation of a dalbavancin order pathway for ABSSSI to avert inpatient admissions at 11 US emergency departments found a mean cost savings of $5133 per patient and $1211 per hospitalization day avoided, compared with inpatient usual care.²⁵

Conversely, a multicenter, retrospective study of 209 patients in a community-based health care system failed to show a financial benefit for dalbavancin use when compared to standard of care for ABSSSI with higher readmission rates.²⁶ Turco et al also reported increased cost results for 64 patients who received dalbavancin vs standard of care for ABSSSI.²⁷ These discordant findings in ABSSSI studies may be impacted by the authors' patient selection choices and cost assumptions, especially with significantly cheaper oral alternatives. More data are needed to best identify the optimal therapeutic use for the long-acting lipoglycopeptides.

Limitations

The most significant limitation in this analysis was selection bias: 38 of 39 patients (97%) who received dalbavancin or oritavancin had a documented reason that described why OPAT therapy with traditional medications would not be optimal, including logistics, AEs, or clinical failures. Most patients treated with vancomycin and daptomycin were admitted into a SNF, RF, or CLC for the remainder of their treatment, allowing for closer monitoring and care compared to patients treated with oritavancin and dalbavancin, but at a greater cost. For patients sent to a community based SNF or RF, laboratory data were not available unless internally drawn or documented in the electronic medical record.

Additionally, not all cost data were available from VA sources; some were applied from literature, pharmacoeconomist, or best faith effort based on workflow. The cost data from third party contractors providing OPAT services to some BVAMC patients during the time frame of this analysis were not available. Due to its small sample size, outliers had the potential to affect averages reported and accuracy of the cost analysis. Emerging evidence suggests that daptomycin doses higher than the manufacturer-recommended regimen may be required for select indications, a factor that could affect cost, AEs, and efficacy outcomes.²⁸ The acquisition cost of oritavancin and dalbavancin may vary by institution (ie, VA contract prices vs non- VA contract prices) and change over time. A current assessment of cost is needed to best visualize institutional benefit.

Finally, while the patient demographic of this MUE was highly representative of the demographic treated at the BVAMC (males aged >65 years), it may not be applicable to external patient populations. This analysis evaluated off-label indications for these medications. Consequently, this analysis would likely not be applicable to non-VA institution, as third-party payers (eg, insurance) are unlikely to cover medications for off-label indications.

CONCLUSIONS

This study found cost savings associated with the use of oritavancin and dalbavancin compared with vancomycin and daptomycin, particularly for the treatment of osteomyelitis. As safety and efficacy data continues to emerge, the use of long-acting lipoglycopeptides appears to be an increasingly attractive alternative option compared to traditional outpatient antimicrobial therapy, depending on the structure of the program. Larger, multicenter cost-effectiveness studies are needed to further establish the impact of these novel agents.

Oritavancin and dalbavancin are long acting lipoglycopeptides indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI).^1,2 Largely due to their long half-lives, prolonged tissue concentrations at sites of infection, tolerability, and minimal requirement for therapeutic drug monitoring, these agents are attractive options in outpatient settings.^3,4 A 1- or 2-dose treatment of oritavancin and dalbavancin may be sufficient for conditions traditionally treated with outpatient parenteral antimicrobial therapy (OPAT) via peripherally inserted central catheter (PICC).

Limited research supports the use of dalbavancin and oritavancin for bone and joint infections, infective endocarditis, and bloodstream infections (BSIs). However, the US Food and Drug Administration has approved an indication for the treatment of ABSSSI.^3-9 Dosing for these off-label indications varies but typically consists of an initial intravenous (IV) dose (1000 mg, 1200 mg, or 1500 mg), with a subsequent dose 1 to 2 weeks later or administered once weekly.^6-10

Due in part to the recent availability of oritavancin and dalbavancin relative to the publication of practice guidelines, their appropriate place in therapy continues to evolve based on emerging literature.^11,12 One potential barrier of use for these medications is their cost. Based on the number of doses administered, the 2022 estimated total acquisition cost of therapy for oritavancin and dalbavancin was $1014 to $4397 and $3046 to $7150, respectively (eAppendix). Despite the high acquisition costs, these agents do not require the placement of an indwelling central line, can be administered in outpatient settings, and require minimal therapeutic dose monitoring compared to vancomycin.^13-15 This medication use evaluation (MUE) compared the total cost of treatment with oritavancin and dalbavancin vs therapies traditionally used for OPAT or prolonged IV inpatient therapy.

METHODS

This retrospective MUE was conducted at the Boise Veterans Affairs Medical Center (BVAMC), a level 2 facility with an extensive rural catchment area. BVAMC provides many OPAT services, including medications, supplies, and dressing changes after initial clinic or inpatient education. Contracted vendors may also assist with at-home nursing care using supplies provided by the BVAMC. Cases were identified using an internal database of OPAT patients and those who received oritavancin or dalbavancin between September 1, 2017, and November 1, 2022. Patients aged ≥ 18 years who received ≥ 1 dose of oritavancin or dalbavancin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were included. Comparator treatments consisting of ≥ 1 week of vancomycin or daptomycin for ABSSSI, osteomyelitis/joint infections, endocarditis, and BSI were identified through review of OPAT and Infectious Diseases service consults during the same timeframe. Patients were excluded if any antibiotic was prescribed by a non- VA clinician, if medications were not provided by OPAT, or if chart review did not identify an ABSSSI, osteomyelitis/ joint infection, or BSI diagnosis.

Electronic medical record review was conducted using a standardized data collection form (eAppendix). Data collected included demographics, infectious diagnosis, treatment administered, administration procedures and related visits and treatment locations, outcomes including clinical failure, adverse events (AEs), and hospital readmission.

Clinical failure was defined as readmission or death due to worsening infection or readmission secondary to a documented potential AE to the evaluated antibiotics within 90 days after initiation. Clinical failures excluded readmissions not associated with infection including comorbidities or elective procedures. AEs included new onset renal failure (serum creatinine ≥ 0.5 mg/dL), neutropenia (neutrophils ≤ 500), thrombocytopenia (platelets < 100,000), eosinophilia (> 15% eosinophils), or creatine phosphokinase > 10 times the upper limit of normal, and Clostridioides difficile (C. difficile) infection. Line complications included thrombophlebitis, local inflammation, or infection requiring line replacement (eAppendix).

A cost-minimization approach was used to assess the total cost of treatment.¹⁶ Patients who received oritavancin or dalbavancin were matched with patients that received vancomycin and daptomycin for the same indication and about 1 month of initiation through the randomization function in Microsoft Excel. This accounted for changes in personnel, nonformulary drug approvals, cost, and changes in practice during the pandemic. Costs were calculated using a decision tree as a base model (Figure 1). In this model, each treatment dyad was assessed for the presence or absence of clinical failure, adverse event (medication and line complications), and treatment setting endpoints. Cost estimates were tabulated for each patient that received treatment using published VA data, literature, pharmacoeconomist guidance, or best faith effort based on workflow. ^17-20 All cost estimates were based on 2022 figures or adjusted for inflation if obtained prior to 2022. Secondary endpoints of this analysis included estimated total cost of medication acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home-health services.

This evaluation was classified by the BVAMC Medication Use Evaluation research determination subcommittee as a quality improvement project and was considered exempt from VA Human Subjects Research requirements based on the VA Policy Handbook guideline 1058.05.

RESULTS

The study identified 44 patients who received dalbavancin or oritavancin between September 1, 2017, and October 31, 2022. Thirty-nine patients were included in the analysis: 24 received oritavancin and 15 received dalbavancin and were matched by indication to 10 patients who received vancomycin and 8 patients who received daptomycin. Three patients could not be matched by indication of ABSSSI (Figure 2). Most patients were male, aged > 65 years, and were treated for osteomyelitis (Table 1). No patients were treated for infective endocarditis. A myriad of concomitant antibiotics were used to treat patients and culture results indicated that most infections treated with oritavancin and dalbavancin were polymicrobial.

The mean total cost of therapy per patient receiving oritavancin, dalbavancin, vancomycin, and daptomycin was $35,630, $59,612, $73,333, and $73,708, respectively (Figure 3). When stratified by indication, 27 patients (69%) in the oritavancin/dalbavancin group were treated for osteomyelitis/ joint infections (16 oritavancin, 11 dalbavancin), 9 patients (23%) were treated for BSI (6 oritavancin, 3 dalbavancin), and 3 patients (8%) were treated for ABSSSI (2 oritavancin, 1 dalbavancin). The mean cost per patient for osteomyelitis/joint infections with oritavancin, dalbavancin, vancomycin, and daptomycin was $34,678, $54,224, $87,488, and $85,044, respectively. The mean cost per patient for BSI for oritavancin, dalbavancin, vancomycin, and daptomycin was $35,048, $75,349, $40,305, and $68,068, respectively. The mean cost per patient for ABSSSI for oritavancin and dalbavancin was $44,771 and $71,672.51.

Estimated total drug cost represents the cost of drug acquisition, administration supplies, laboratory monitoring, and human resources for OPAT visits or receiving home health services. The mean cost per patient of drug-related therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2203, $5924, $3637, and $7146, respectively (Table 2).

The mean cost per patient for osteomyelitis therapy for oritavancin, dalbavancin, vancomycin, and daptomycin was $2375, $6775, $4164, $8152, respectively. The mean cost of per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $1737, $3475, $2409, and $1016, respectively. The mean cost per patient for oritavancin and dalbavancin for ABSSSI treatment, was $1553 and $3910, respectively.

Setting-related costs include expenses from inpatient admissions and postdischarge stays at community living centers (CLCs), skilled nursing facilities (SNFs), or rehabilitation facilities (RFs) for the duration of antimicrobial therapy. The mean setting-related therapy cost for osteomyelitis treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $27,852, $17,815, $83,324, and $72,856, respectively. The mean setting-related therapy cost per patient for BSI treatment with oritavancin, dalbavancin, vancomycin, and daptomycin was $33,310, $60,668, $37,734, and $67,074, respectively. The mean setting-related therapy cost per patient for ABSSSI treatment for oritavancin and dalbavancin was $43,218 and $67,762.00, respectively.

Six of 39 patients (15%) had clinical failure: 2 patients with oritavancin and 4 patients with dalbavancin. Four patients were readmitted for worsening infection and 2 for AEs. One patient (13%) in the daptomycin group had clinical failure due to readmission for worsening infection. There was no clinical failure with vancomycin. The costs associated with clinical failure per patient for oritavancin, dalbavancin, vancomycin, and daptomycin were $2925, $23,972, $0, and $3601, respectively (Table 3).

Thirty-eight patients (97%) who received oritavancin or dalbavancin had difficulty adhering to vancomycin or daptomycin OPAT. Oritavancin or dalbavancin was used in 10 patients (26%) who lacked support at home and 15 patients (38%) who had either a contraindication or previous failure with other antimicrobials, which were the most common explanations.

DISCUSSION

Long-acting lipoglycopeptides represent a potential alternative to home IV therapy that can avoid prolonged IV access with traditional OPAT. This offers significant advantages, allowing patients to be discharged from the hospital early, especially in rural areas with little OPAT infrastructure or those with logistic challenges. In this analysis, treatment with oritavancin for osteomyelitis, BSI, or ABSSSI, yielded an estimated cost savings of about $37,000 per patient, compared to treatment of matched indications with vancomycin and daptomycin. For every patient treated with dalbavancin for osteomyelitis, BSI, or ABSSSI, the cost savings was about $13,000 per patient, compared to treatment of matched indications for daptomycin and vancomycin. The estimated cost savings per patient for oritavancin was similar to previously published projections ($30,500 to $55,831).¹⁵

Cost savings were primarily driven by setting-related costs. The greatest contrast between the oritavancin and dalbavancin group compared to the vancomycin and daptomycin group was the length of stay in a postdischarge CLC, SNF, or RF setting. This analysis estimated that for every patient treated with oritavancin for osteomyelitis, the setting-related cost savings per patient was about $55,000 compared with vancomycin, and about $45,000 per patient compared with daptomycin. Furthermore, the estimated setting-related cost savings for osteomyelitis treatment with dalbavancin was about $65,000 compared with vancomycin and about $55,000 compared with daptomycin.

Clinical failure occurred with greater frequency in the oritavancin and dalbavancin groups (15%), compared with the vancomycin (0%) and daptomycin (13%) groups. Although the clinical failure rates in patients with osteomyelitis treated with oritavancin and dalbavancin compared with daptomycin were like those in previously published research (10%-30%), the rates of clinical failure for vancomycin in this analysis were lower than those in the oritavancin and dalbavancin group.^8,21,22 The discrepancy in clinical failure rates between this analysis and previous research is likely due to selection bias. Based on the percentages of clinical failure found in the analysis, it is not surprising to note that the total clinical failure-related cost per patient was higher for oritavancin and dalbavancin compared to vancomycin, but similar between oritavancin and daptomycin.

This analysis also found that 15% of patients in the oritavancin and dalbavancin group experienced an AE compared to 10% of patients in the vancomycin group and none in the daptomycin group. In the oritavancin and dalbavancin group, the 2 most common AEs were infusion-related reactions and C. difficile colitis. Although infusion related reactions are easier to correspond to oritavancin and dalbavancin, it becomes difficult to definitively attribute the occurrence of C. difficile to these drugs as many patients were receiving concomitant antibiotics. Although not a primary or secondary objective, the rate of IV-line AEs were more prevalent in the vancomycin (10%), and daptomycin (13%) groups, compared to none in the oritavancin and dalbavancin group. This finding was expected; oritavancin and dalbavancin do not require a central IV line for administration.

Pharmacoeconomic literature continues to emerge with long-acting lipoglycopeptides. A 2024 Italian retrospective single-center analysis of 62 patients reported mean cost reductions > €3200 per patient (> $3400) given dalbavancin compared with the standard of care for ABSSSI or more deep-seeded infections such as osteomyelitis.²³ A 2023 Spanish observational multicenter analysis of 124 patients with infective endocarditis demonstrated high efficacy, safety and cost-effectiveness with dalbavancin vs conventional treatments, with a mean savings of > €5548 per patient (> $6200).²⁴ An analysis of the implementation of a dalbavancin order pathway for ABSSSI to avert inpatient admissions at 11 US emergency departments found a mean cost savings of $5133 per patient and $1211 per hospitalization day avoided, compared with inpatient usual care.²⁵

Conversely, a multicenter, retrospective study of 209 patients in a community-based health care system failed to show a financial benefit for dalbavancin use when compared to standard of care for ABSSSI with higher readmission rates.²⁶ Turco et al also reported increased cost results for 64 patients who received dalbavancin vs standard of care for ABSSSI.²⁷ These discordant findings in ABSSSI studies may be impacted by the authors' patient selection choices and cost assumptions, especially with significantly cheaper oral alternatives. More data are needed to best identify the optimal therapeutic use for the long-acting lipoglycopeptides.

Limitations

The most significant limitation in this analysis was selection bias: 38 of 39 patients (97%) who received dalbavancin or oritavancin had a documented reason that described why OPAT therapy with traditional medications would not be optimal, including logistics, AEs, or clinical failures. Most patients treated with vancomycin and daptomycin were admitted into a SNF, RF, or CLC for the remainder of their treatment, allowing for closer monitoring and care compared to patients treated with oritavancin and dalbavancin, but at a greater cost. For patients sent to a community based SNF or RF, laboratory data were not available unless internally drawn or documented in the electronic medical record.

Additionally, not all cost data were available from VA sources; some were applied from literature, pharmacoeconomist, or best faith effort based on workflow. The cost data from third party contractors providing OPAT services to some BVAMC patients during the time frame of this analysis were not available. Due to its small sample size, outliers had the potential to affect averages reported and accuracy of the cost analysis. Emerging evidence suggests that daptomycin doses higher than the manufacturer-recommended regimen may be required for select indications, a factor that could affect cost, AEs, and efficacy outcomes.²⁸ The acquisition cost of oritavancin and dalbavancin may vary by institution (ie, VA contract prices vs non- VA contract prices) and change over time. A current assessment of cost is needed to best visualize institutional benefit.

Finally, while the patient demographic of this MUE was highly representative of the demographic treated at the BVAMC (males aged >65 years), it may not be applicable to external patient populations. This analysis evaluated off-label indications for these medications. Consequently, this analysis would likely not be applicable to non-VA institution, as third-party payers (eg, insurance) are unlikely to cover medications for off-label indications.

CONCLUSIONS

This study found cost savings associated with the use of oritavancin and dalbavancin compared with vancomycin and daptomycin, particularly for the treatment of osteomyelitis. As safety and efficacy data continues to emerge, the use of long-acting lipoglycopeptides appears to be an increasingly attractive alternative option compared to traditional outpatient antimicrobial therapy, depending on the structure of the program. Larger, multicenter cost-effectiveness studies are needed to further establish the impact of these novel agents.

Research on cannabis use disorder (CUD) has mainly focused on individuals aged < 65 years, but a recently published study in JAMA Network Open found one-third of older veterans who had used cannabis in the previous 30 days screened positive for CUD.

The cross-sectional study of 4503 veterans aged 65 to 84 years from the US Department of Veterans Affairs (VA) Cannabis and Aging Cohort found 57% of participants reported lifetime cannabis use, with 29% citing medical reasons, usually for pain management. About 10% reported using cannabis in the previous 30 days, with 52% reporting use for ≥ 20 days in a month. The odds of CUD were higher among men, respondents aged < 76 years, individuals with anxiety, and individuals who reported any illicit drug use or frequent cannabis use.

In 2019, 9.8% of veterans reported using cannabis in the previous year. In 2019 to 2020, > 20% of veterans aged 18 to 44 years said they had used cannabis in the previous 6 months. According to VA Health Systems Research, about 1 in 11 veterans had used cannabis in the previous year. Compared to the general US population, recent cannabis use was similar or slightly lower among veterans. Among those with previous year use, however, the percentage of veterans using cannabis for medical purposes was more than double that of the general population.

Older veterans are particularly at risk for CUD. Cannabis use can increase the chance of neuropsychiatric disorders, respiratory symptoms, and cardiovascular outcomes—all leading causes of death in older adults. They also have an elevated risk of suicidal ideation and therefore may be particularly susceptible to adverse effects of cannabis, even if used for therapeutic purposes.

In addition to CUD, older veterans may be at risk for tetrahydrocannabinol (THC) intoxication if they are unable to tolerate cannabis potency or the latent THC components found in products marketed as only having cannabidiol. THC is the primary psychoactive compound found in the cannabis plant and interacts with brain cannabinoid receptors to affect mood, perception, and various bodily functions. Cannabis potency has increased from about 3% in the 1980s to about 15% in recent years; the average THC-to-CBD ratio has increased substantially over the past decade.

Unlike veterans aged 18 to 25 years, those aged ≥ 65 years are less likely to use recreational cannabis, are more likely to use medicinal cannabis recommended by a health care professional, and report use for pain management, insomnia, and mental health (including posttraumatic stress disorder [PTSD]). Some research indicates that rates of cannabis use and CUD are particularly elevated among veterans with PTSD and major depressive disorder who may use cannabis as a means of coping with negative affect and sleep disturbances. PTSD is recognized as a qualifying condition by states that have legalized medicinal cannabis. 

Sleep disturbance, especially in conjunction with PTSD, is associated with CUD among veterans. According to the VA, research does not support cannabis as an effective PTSD treatment, a reason the 2023 VA/DoD Clinical Practice Guideline for PTSD does not recommend it for that use. In 2020, lifetime prevalence of CUD among veterans was 9.2%; the prevalence of past-6-month CUD diagnoses among veterans was 2.7%. Among veterans with PTSD, however, CUD rates were much higher (12.1%).

Current VA guidelines recommend that patients with CUD be offered referral to mental health services for evidence-based treatments, including motivational interviews, contingency management, and cognitive behavioral therapy. The JAMA Network Open study notes the importance of screening and informing older veterans about the risks of cannabis use: “Unidentified, patients cannot be offered existing evidence-based treatments. Despite increasing cannabis use among older adults, there is an inadequate evidence base on therapeutic benefits and potential harms from cannabis use among older people.”

Research on cannabis use disorder (CUD) has mainly focused on individuals aged < 65 years, but a recently published study in JAMA Network Open found one-third of older veterans who had used cannabis in the previous 30 days screened positive for CUD.

The cross-sectional study of 4503 veterans aged 65 to 84 years from the US Department of Veterans Affairs (VA) Cannabis and Aging Cohort found 57% of participants reported lifetime cannabis use, with 29% citing medical reasons, usually for pain management. About 10% reported using cannabis in the previous 30 days, with 52% reporting use for ≥ 20 days in a month. The odds of CUD were higher among men, respondents aged < 76 years, individuals with anxiety, and individuals who reported any illicit drug use or frequent cannabis use.

In 2019, 9.8% of veterans reported using cannabis in the previous year. In 2019 to 2020, > 20% of veterans aged 18 to 44 years said they had used cannabis in the previous 6 months. According to VA Health Systems Research, about 1 in 11 veterans had used cannabis in the previous year. Compared to the general US population, recent cannabis use was similar or slightly lower among veterans. Among those with previous year use, however, the percentage of veterans using cannabis for medical purposes was more than double that of the general population.

Older veterans are particularly at risk for CUD. Cannabis use can increase the chance of neuropsychiatric disorders, respiratory symptoms, and cardiovascular outcomes—all leading causes of death in older adults. They also have an elevated risk of suicidal ideation and therefore may be particularly susceptible to adverse effects of cannabis, even if used for therapeutic purposes.

In addition to CUD, older veterans may be at risk for tetrahydrocannabinol (THC) intoxication if they are unable to tolerate cannabis potency or the latent THC components found in products marketed as only having cannabidiol. THC is the primary psychoactive compound found in the cannabis plant and interacts with brain cannabinoid receptors to affect mood, perception, and various bodily functions. Cannabis potency has increased from about 3% in the 1980s to about 15% in recent years; the average THC-to-CBD ratio has increased substantially over the past decade.

Unlike veterans aged 18 to 25 years, those aged ≥ 65 years are less likely to use recreational cannabis, are more likely to use medicinal cannabis recommended by a health care professional, and report use for pain management, insomnia, and mental health (including posttraumatic stress disorder [PTSD]). Some research indicates that rates of cannabis use and CUD are particularly elevated among veterans with PTSD and major depressive disorder who may use cannabis as a means of coping with negative affect and sleep disturbances. PTSD is recognized as a qualifying condition by states that have legalized medicinal cannabis. 

Sleep disturbance, especially in conjunction with PTSD, is associated with CUD among veterans. According to the VA, research does not support cannabis as an effective PTSD treatment, a reason the 2023 VA/DoD Clinical Practice Guideline for PTSD does not recommend it for that use. In 2020, lifetime prevalence of CUD among veterans was 9.2%; the prevalence of past-6-month CUD diagnoses among veterans was 2.7%. Among veterans with PTSD, however, CUD rates were much higher (12.1%).

Current VA guidelines recommend that patients with CUD be offered referral to mental health services for evidence-based treatments, including motivational interviews, contingency management, and cognitive behavioral therapy. The JAMA Network Open study notes the importance of screening and informing older veterans about the risks of cannabis use: “Unidentified, patients cannot be offered existing evidence-based treatments. Despite increasing cannabis use among older adults, there is an inadequate evidence base on therapeutic benefits and potential harms from cannabis use among older people.”

Research on cannabis use disorder (CUD) has mainly focused on individuals aged < 65 years, but a recently published study in JAMA Network Open found one-third of older veterans who had used cannabis in the previous 30 days screened positive for CUD.

The cross-sectional study of 4503 veterans aged 65 to 84 years from the US Department of Veterans Affairs (VA) Cannabis and Aging Cohort found 57% of participants reported lifetime cannabis use, with 29% citing medical reasons, usually for pain management. About 10% reported using cannabis in the previous 30 days, with 52% reporting use for ≥ 20 days in a month. The odds of CUD were higher among men, respondents aged < 76 years, individuals with anxiety, and individuals who reported any illicit drug use or frequent cannabis use.

In 2019, 9.8% of veterans reported using cannabis in the previous year. In 2019 to 2020, > 20% of veterans aged 18 to 44 years said they had used cannabis in the previous 6 months. According to VA Health Systems Research, about 1 in 11 veterans had used cannabis in the previous year. Compared to the general US population, recent cannabis use was similar or slightly lower among veterans. Among those with previous year use, however, the percentage of veterans using cannabis for medical purposes was more than double that of the general population.

Older veterans are particularly at risk for CUD. Cannabis use can increase the chance of neuropsychiatric disorders, respiratory symptoms, and cardiovascular outcomes—all leading causes of death in older adults. They also have an elevated risk of suicidal ideation and therefore may be particularly susceptible to adverse effects of cannabis, even if used for therapeutic purposes.

In addition to CUD, older veterans may be at risk for tetrahydrocannabinol (THC) intoxication if they are unable to tolerate cannabis potency or the latent THC components found in products marketed as only having cannabidiol. THC is the primary psychoactive compound found in the cannabis plant and interacts with brain cannabinoid receptors to affect mood, perception, and various bodily functions. Cannabis potency has increased from about 3% in the 1980s to about 15% in recent years; the average THC-to-CBD ratio has increased substantially over the past decade.

Unlike veterans aged 18 to 25 years, those aged ≥ 65 years are less likely to use recreational cannabis, are more likely to use medicinal cannabis recommended by a health care professional, and report use for pain management, insomnia, and mental health (including posttraumatic stress disorder [PTSD]). Some research indicates that rates of cannabis use and CUD are particularly elevated among veterans with PTSD and major depressive disorder who may use cannabis as a means of coping with negative affect and sleep disturbances. PTSD is recognized as a qualifying condition by states that have legalized medicinal cannabis. 

Sleep disturbance, especially in conjunction with PTSD, is associated with CUD among veterans. According to the VA, research does not support cannabis as an effective PTSD treatment, a reason the 2023 VA/DoD Clinical Practice Guideline for PTSD does not recommend it for that use. In 2020, lifetime prevalence of CUD among veterans was 9.2%; the prevalence of past-6-month CUD diagnoses among veterans was 2.7%. Among veterans with PTSD, however, CUD rates were much higher (12.1%).

Current VA guidelines recommend that patients with CUD be offered referral to mental health services for evidence-based treatments, including motivational interviews, contingency management, and cognitive behavioral therapy. The JAMA Network Open study notes the importance of screening and informing older veterans about the risks of cannabis use: “Unidentified, patients cannot be offered existing evidence-based treatments. Despite increasing cannabis use among older adults, there is an inadequate evidence base on therapeutic benefits and potential harms from cannabis use among older people.”

The COVID-19 pandemic changed the education and training experiences of health care students and those set to comprise the future workforce. Apart from general training disruptions or delays due to the pandemic, behavioral health trainees such as psychologists and social workers faced limited opportunities to provide in-person services.^1-5 Trainees also experienced fewer referrals to mental health services from primary care and more disrupted, no-show, or cancelled appointments.^4-6 Behavioral health trainees experienced a limited ability to establish rapport and more difficulty providing effective services because of the limited in-person interaction presented by telehealth.⁶ The pandemic also resulted in feelings of increased isolation and decreased teamwork.^1,7 The virtual or remote setting made it more difficult for trainees to feel as if they were a member of a team or community of behavioral health professionals.^1,7

Behavioral health trainees had to adapt to conducting patient visits and educational didactics through virtual platforms.^1,3-7 Challenges included access or technological problems with online platforms and a lack of telehealth training use.^3,4,6 One study found that while both behavioral health trainees and licensed practitioners reported similar rates of telehealth use for mental health services by early April 2020, trainees had more difficulties implementing telehealth compared with licensed practitioners. This study found that US Department of Veteran Affairs (VA) facilities reported higher use of telehealth in February 2020.⁵

A mission of the VA is to provide education and training to health care professionals through partnerships with affiliated academic institutions. The VA is the largest education and training supplier for health care professions in the US. As many as 50% of psychologists in the US received some training at the VA.⁸ Additionally, more graduate-level social work students are trained at the VA than at any other organization.⁹ The VA is a major contributor to not only its own behavioral health workforce, but that of the entire country.

The VA is also the largest employer of psychologists and social workers in the US.^10,11 The VA Office of Academic Affiliations (OAA) oversees health care profession education and training at all VA facilities. In 2012, OAA began the Mental Health Education Expansion program to increase training for behavioral health professionals, including psychologists and social workers. ¹² The OAA initiative was aligned with VA training and workforce priorities.^8,12 To gauge the effectiveness of VA education and training, OAA encourages VA trainees to complete the Trainee Satisfaction Survey (TSS), which measures trainee satisfaction and the likelihood of a trainee to consider the VA for future employment.

Researchers at the Veterans Emergency Management Evaluation Center sought to understand the impact the COVID-19 pandemic had on behavioral health trainees’ experiences by examining TSS data from before and after the onset of the pandemic. This study expands on prior research among physician residents and fellows which found associations between VA training experiences and the COVID- 19 pandemic. The previous study found declines in trainee satisfaction and a decreased likelihood to consider the VA for future employment.¹³

It is important to understand the effects the pandemic had on the professional development and wellness for both physician and behavioral health professional trainees. Identifying how the pandemic impacted trainee satisfaction may help improve education programs and mitigate the impact of future public health emergencies. This is particularly important due to the shortage of behavioral health professionals in the VA and the US.^12,14

METHODS

This study used TSS data collected from August 2018 to July 2021 from 153 VA facilities. A behavioral health trainee was defined as any psychology or social work trainee who completed 1 rotation at a VA facility. Psychiatric trainees were excluded because as physicians their training programs differ markedly from those for psychology and social work. Excluding psychiatry, psychology and social work comprise the 2 largest mental health care training groups.

This study was reviewed and approved as a quality improvement project by the VA Greater Los Angeles Healthcare System (VAGLAHS) Institutional Review Board, which waived informed consent requirements. The OAA granted access to data using a process open to all VA researchers. At the time of data collection, respondents were assured their anonymity; participation was voluntary.

Measures

Any response provided before February 29, 2020, was defined as the prepandemic period. The pandemic period included any response from April 1, 2020, to July 31, 2021. Responses collected in March 2020 were excluded as it would be unclear from the survey whether the training period occurred before or after the onset of the pandemic.

To measure overall trainee satisfaction with the VA training experience, responses were grouped as satisfied (satisfied/ very satisfied) and dissatisfied (dissatisfied/ very dissatisfied). To measure a trainee’s likelihood to consider the VA for future employment as a result of their training experience, responses were grouped as likely (likely/very likely) and unlikely (unlikely/very unlikely).

Other components of satisfaction were also collected including onboarding, clinical faculty/preceptors, clinical learning environment, physical environment, working environment, and respect felt at work. If a respondent chose very dissatisfied or dissatisfied, they were subsequently asked to specify the reason for their dissatisfaction with an open-ended response. Open-ended responses were not permitted if a respondent indicated a satisfied or very satisfied response.

Statistical Analyses

Stata SE 17 was used for statistical analyses. To test the relationship between the pandemic group and the 2 separate outcome variables, logistic regressions were conducted to measure overall satisfaction and likelihood of future VA employment. Margin commands were used to calculate the difference in the probability of reporting satisfied/very satisfied and likely/very likely for the prepandemic and pandemic groups. The association of the COVID-19 group with each outcome variable was expressed as the difference in the percentage of the outcome between the prepandemic and pandemic groups. Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees; therefore, the groups were combined.

Rapid Coding and Thematic Analyses

Qualitative data were based on open-ended responses from behavioral health trainees when they were asked to specify the cause of dissatisfaction in the aforementioned areas of satisfaction. Methods for qualitative data included rapid coding and thematic content analyses.^15,16 Additional general information regarding the qualitative data analyses is described elsewhere.¹³ A keyword search was completed to identify all open-ended responses related to COVID-19 pandemic causes of dissatisfaction. Keywords included: virus, COVID, corona, pandemic, PPE, N95, mask, social distance, and safety. All open-ended responses were reviewed to ensure keywords were appropriately identifying pandemic-related causes of dissatisfaction and did not overlook other references to the pandemic, and to identify initial themes and corresponding definitions based on survey questions. After review, additional keywords were included in the content analyses that were related to providing mental health services using remote or telehealth options. This included the following keywords: remote, video, VVC (VA Video Connect), and tele. The research team completed a review of the initial themes and definitions and created a final coding construct with definitions before completing an independent coding of all identified pandemic-related responses. Frequency counts of each code were provided to identify which pandemic-related causes of dissatisfaction were mentioned most.

RESULTS

A total of 3950 behavioral health trainees responded to the TSS, including 2715 psychology trainees and 1235 social work trainees who indicated they received training at the VA in academic years 2018/2019, 2019/2020, or 2020/2021. The academic year 2018/2019 was considered in an effort to provide a larger sample of prepandemic trainees.

The percentage of trainees reporting satisfaction with their training decreased across prepandemic to pandemic groups. In the pandemic group, 2166 of 2324 respondents (93.2%) reported satisfaction compared to 1474 of 1555 (94.8%) in the prepandemic trainee group (P = .04; 95% CI, -3.10 to -0.08). There was no association between the pandemic group and behavioral health trainees’ reported willingness to consider the VA for future employment (Table 1). Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees, therefore the groups were combined, and overall effects were reported.

Pandemic-Related Dissatisfaction

Of the 3950 psychology and social work trainees who responded to the survey, 75 (1.9%) indicated dissatisfaction with their VA training experience using pandemic-related keywords. Open-ended responses were generally short (range, 1-32 words; median, 19 words). Qualitative analyses revealed 7 themes (Table 2).

The most frequently identified theme was challenges with onboarding. One respondent indicated the modified onboarding procedures in place due to the pandemic were difficult to understand and resulted in delays. Another frequently mentioned cause of dissatisfaction was limited work or office space and insufficient computer availability. This was often noted to relate to a lack of private space to conduct telehealth visits or computers that were not equipped to provide telehealth. Several respondents also noted technological issues when attempting to use VVC to provide telehealth.

Another common theme was that the pandemic diminished teamwork, generated feelings of isolation, and created unsupportive environments for trainees. For instance, some trainees indicated that COVID-19 decreased the inclusion of trainees as part of the regular staff groups and accordingly resulted in limited networking opportunities. Other causes of dissatisfaction included the pandemic’s impacts on the learning environment, such as decreases in patient volume, decreased diversity of patient cases, and a limited presence of faculty mentors. Several respondents indicated that the pandemic limited their caseloads and indicated that most patients were seen virtually. Open-ended responses from a few respondents indicated their training environments were noncompliant with social distancing, personal protective equipment requirements, or other safety guidelines.

DISCUSSION

This study illustrates the impact of the COVID-19 pandemic on the behavioral health trainee experience, which was expressed through decreased satisfaction with their clinical training at the VA. The narrative data indicated that the observed pandemic-related dissatisfaction was linked specifically to onboarding, a lack of safe and private workspaces and computers, as well as a lack of a supportive work environment.

Although the reported decrease in satisfaction was statistically significant, the effect size was not large. Additionally, while satisfaction did decrease, the trainees’ reported likelihood to consider the VA for future employment was not impacted. This may suggest psychologist and social work trainees’ perseverance and dedication to their chosen profession persisted despite the challenges presented by the pandemic. Furthermore, the qualitative data suggest potential ways to mitigate health care profession trainee challenges that can follow a crisis like the COVID-19 pandemic, although further study is warranted.

While narrative responses with pandemic-related keywords did indicate challenges specific to COVID-19 (ie, limited access to workspaces and/or computers equipped for telehealth), the overall frequency of pandemic-related responses was low. This may indicate these are institutional challenges trainees face independent of the pandemic. These findings warrant longterm attention to the satisfaction of psychology and social worker trainees’ during the pandemic. For example, additional training for the use of telehealth could be provided. One study indicated that < 61% of psychology postdoctoral fellows received telepsychology training during the pandemic, and of those who did receive training, less than half were satisfied with it.³

Similarly, strategies could be developed to ensure a more supportive learning and work environment, and provide additional networking opportunities for trainees, despite social distancing. Education specific to disaster response should be incorporated into behavioral health care professionals’ training, especially because behavioral health care professionals provided major contributions during the pandemic due to reported increases in mental health concerns (eg, anxiety and depression) during the period.^7,17,18 As the pandemic progressed, policies and procedures were established or modified to address some of these concerns because they were not necessarily limited to trainees. For example, additional training resources were developed to support the use of various telehealth technologies, virtual resources were used more often for meetings, and supervisors developed more comfort and familiarity with how to manage in a virtual or hybrid environment.

Limitations

Although the TSS data provide a large national sample of behavioral health care trainees, it only includes VA trainees, and therefore may not be completely generalizable across health care. However, because many psychologists and social workers throughout the US train at the VA, and because the VA is the largest employer of practicing psychologists and social workers, understanding the impacts felt at the VA informs institutions nationally.^8-11 The TSS has limited demographic data (eg, age, race, ethnicity, and sex), so it is unclear whether the respondent groups before and during the pandemic differed in ways that could relate to outcomes. The data also do not specify exact training dates; however, anecdotal evidence suggests respondents generally complete the survey close to the end of their training.

Additionally, open-ended narrative responses were only asked for replies that indicated dissatisfaction, precluding a more nuanced understanding of potential positive outcomes. Furthermore, the TSS is limited to questions about the trainees’ clinical experiences, but because the pandemic created many stressors, there may have been personal issues that affected their work. It is possible that changes in overall satisfaction may have been rooted in something outside of their clinical experience. Finally, the response rate for the TSS is consistently low both before and during the pandemic and includes a limited number of narrative responses.

CONCLUSIONS

The VA is an important contributor to the education, training, and composition of the behavioral health care workforce. A deeper understanding of the VA trainee experience is important to identify how to improve behavioral health care professional education and training. This is especially true as behavioral health care faces shortages within the VA and nationwide.^8,12,19

This study reinforces research that found health care trainees experienced decreased learning opportunities and telehealth-related challenges during the COVID-19 pandemic. ^13,20 Despite the observed decline in trainee satisfaction, the lack of a corresponding change in likelihood to seek employment with the VA is encouraging for VA efforts to maintain and grow its behavioral health care workforce and for similar efforts outside VA. This resilience may relate to the substantial prepandemic time invested in their professional development. Future studies should examine long term impacts of the pandemic on trainee’s clinical experience and whether the pipeline of behavioral health care workers declines over time as students that are earlier in their career paths instead chose other professions. Future research should also explore ways to improve professional development and wellness of behavioral health care trainees during disasters (eg, telehealth training, additional networking, and social support).

The COVID-19 pandemic changed the education and training experiences of health care students and those set to comprise the future workforce. Apart from general training disruptions or delays due to the pandemic, behavioral health trainees such as psychologists and social workers faced limited opportunities to provide in-person services.^1-5 Trainees also experienced fewer referrals to mental health services from primary care and more disrupted, no-show, or cancelled appointments.^4-6 Behavioral health trainees experienced a limited ability to establish rapport and more difficulty providing effective services because of the limited in-person interaction presented by telehealth.⁶ The pandemic also resulted in feelings of increased isolation and decreased teamwork.^1,7 The virtual or remote setting made it more difficult for trainees to feel as if they were a member of a team or community of behavioral health professionals.^1,7

Behavioral health trainees had to adapt to conducting patient visits and educational didactics through virtual platforms.^1,3-7 Challenges included access or technological problems with online platforms and a lack of telehealth training use.^3,4,6 One study found that while both behavioral health trainees and licensed practitioners reported similar rates of telehealth use for mental health services by early April 2020, trainees had more difficulties implementing telehealth compared with licensed practitioners. This study found that US Department of Veteran Affairs (VA) facilities reported higher use of telehealth in February 2020.⁵

A mission of the VA is to provide education and training to health care professionals through partnerships with affiliated academic institutions. The VA is the largest education and training supplier for health care professions in the US. As many as 50% of psychologists in the US received some training at the VA.⁸ Additionally, more graduate-level social work students are trained at the VA than at any other organization.⁹ The VA is a major contributor to not only its own behavioral health workforce, but that of the entire country.

The VA is also the largest employer of psychologists and social workers in the US.^10,11 The VA Office of Academic Affiliations (OAA) oversees health care profession education and training at all VA facilities. In 2012, OAA began the Mental Health Education Expansion program to increase training for behavioral health professionals, including psychologists and social workers. ¹² The OAA initiative was aligned with VA training and workforce priorities.^8,12 To gauge the effectiveness of VA education and training, OAA encourages VA trainees to complete the Trainee Satisfaction Survey (TSS), which measures trainee satisfaction and the likelihood of a trainee to consider the VA for future employment.

Researchers at the Veterans Emergency Management Evaluation Center sought to understand the impact the COVID-19 pandemic had on behavioral health trainees’ experiences by examining TSS data from before and after the onset of the pandemic. This study expands on prior research among physician residents and fellows which found associations between VA training experiences and the COVID- 19 pandemic. The previous study found declines in trainee satisfaction and a decreased likelihood to consider the VA for future employment.¹³

It is important to understand the effects the pandemic had on the professional development and wellness for both physician and behavioral health professional trainees. Identifying how the pandemic impacted trainee satisfaction may help improve education programs and mitigate the impact of future public health emergencies. This is particularly important due to the shortage of behavioral health professionals in the VA and the US.^12,14

METHODS

This study used TSS data collected from August 2018 to July 2021 from 153 VA facilities. A behavioral health trainee was defined as any psychology or social work trainee who completed 1 rotation at a VA facility. Psychiatric trainees were excluded because as physicians their training programs differ markedly from those for psychology and social work. Excluding psychiatry, psychology and social work comprise the 2 largest mental health care training groups.

This study was reviewed and approved as a quality improvement project by the VA Greater Los Angeles Healthcare System (VAGLAHS) Institutional Review Board, which waived informed consent requirements. The OAA granted access to data using a process open to all VA researchers. At the time of data collection, respondents were assured their anonymity; participation was voluntary.

Measures

Any response provided before February 29, 2020, was defined as the prepandemic period. The pandemic period included any response from April 1, 2020, to July 31, 2021. Responses collected in March 2020 were excluded as it would be unclear from the survey whether the training period occurred before or after the onset of the pandemic.

To measure overall trainee satisfaction with the VA training experience, responses were grouped as satisfied (satisfied/ very satisfied) and dissatisfied (dissatisfied/ very dissatisfied). To measure a trainee’s likelihood to consider the VA for future employment as a result of their training experience, responses were grouped as likely (likely/very likely) and unlikely (unlikely/very unlikely).

Other components of satisfaction were also collected including onboarding, clinical faculty/preceptors, clinical learning environment, physical environment, working environment, and respect felt at work. If a respondent chose very dissatisfied or dissatisfied, they were subsequently asked to specify the reason for their dissatisfaction with an open-ended response. Open-ended responses were not permitted if a respondent indicated a satisfied or very satisfied response.

Statistical Analyses

Stata SE 17 was used for statistical analyses. To test the relationship between the pandemic group and the 2 separate outcome variables, logistic regressions were conducted to measure overall satisfaction and likelihood of future VA employment. Margin commands were used to calculate the difference in the probability of reporting satisfied/very satisfied and likely/very likely for the prepandemic and pandemic groups. The association of the COVID-19 group with each outcome variable was expressed as the difference in the percentage of the outcome between the prepandemic and pandemic groups. Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees; therefore, the groups were combined.

Rapid Coding and Thematic Analyses

Qualitative data were based on open-ended responses from behavioral health trainees when they were asked to specify the cause of dissatisfaction in the aforementioned areas of satisfaction. Methods for qualitative data included rapid coding and thematic content analyses.^15,16 Additional general information regarding the qualitative data analyses is described elsewhere.¹³ A keyword search was completed to identify all open-ended responses related to COVID-19 pandemic causes of dissatisfaction. Keywords included: virus, COVID, corona, pandemic, PPE, N95, mask, social distance, and safety. All open-ended responses were reviewed to ensure keywords were appropriately identifying pandemic-related causes of dissatisfaction and did not overlook other references to the pandemic, and to identify initial themes and corresponding definitions based on survey questions. After review, additional keywords were included in the content analyses that were related to providing mental health services using remote or telehealth options. This included the following keywords: remote, video, VVC (VA Video Connect), and tele. The research team completed a review of the initial themes and definitions and created a final coding construct with definitions before completing an independent coding of all identified pandemic-related responses. Frequency counts of each code were provided to identify which pandemic-related causes of dissatisfaction were mentioned most.

RESULTS

A total of 3950 behavioral health trainees responded to the TSS, including 2715 psychology trainees and 1235 social work trainees who indicated they received training at the VA in academic years 2018/2019, 2019/2020, or 2020/2021. The academic year 2018/2019 was considered in an effort to provide a larger sample of prepandemic trainees.

The percentage of trainees reporting satisfaction with their training decreased across prepandemic to pandemic groups. In the pandemic group, 2166 of 2324 respondents (93.2%) reported satisfaction compared to 1474 of 1555 (94.8%) in the prepandemic trainee group (P = .04; 95% CI, -3.10 to -0.08). There was no association between the pandemic group and behavioral health trainees’ reported willingness to consider the VA for future employment (Table 1). Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees, therefore the groups were combined, and overall effects were reported.

Pandemic-Related Dissatisfaction

Of the 3950 psychology and social work trainees who responded to the survey, 75 (1.9%) indicated dissatisfaction with their VA training experience using pandemic-related keywords. Open-ended responses were generally short (range, 1-32 words; median, 19 words). Qualitative analyses revealed 7 themes (Table 2).

The most frequently identified theme was challenges with onboarding. One respondent indicated the modified onboarding procedures in place due to the pandemic were difficult to understand and resulted in delays. Another frequently mentioned cause of dissatisfaction was limited work or office space and insufficient computer availability. This was often noted to relate to a lack of private space to conduct telehealth visits or computers that were not equipped to provide telehealth. Several respondents also noted technological issues when attempting to use VVC to provide telehealth.

Another common theme was that the pandemic diminished teamwork, generated feelings of isolation, and created unsupportive environments for trainees. For instance, some trainees indicated that COVID-19 decreased the inclusion of trainees as part of the regular staff groups and accordingly resulted in limited networking opportunities. Other causes of dissatisfaction included the pandemic’s impacts on the learning environment, such as decreases in patient volume, decreased diversity of patient cases, and a limited presence of faculty mentors. Several respondents indicated that the pandemic limited their caseloads and indicated that most patients were seen virtually. Open-ended responses from a few respondents indicated their training environments were noncompliant with social distancing, personal protective equipment requirements, or other safety guidelines.

DISCUSSION

This study illustrates the impact of the COVID-19 pandemic on the behavioral health trainee experience, which was expressed through decreased satisfaction with their clinical training at the VA. The narrative data indicated that the observed pandemic-related dissatisfaction was linked specifically to onboarding, a lack of safe and private workspaces and computers, as well as a lack of a supportive work environment.

Although the reported decrease in satisfaction was statistically significant, the effect size was not large. Additionally, while satisfaction did decrease, the trainees’ reported likelihood to consider the VA for future employment was not impacted. This may suggest psychologist and social work trainees’ perseverance and dedication to their chosen profession persisted despite the challenges presented by the pandemic. Furthermore, the qualitative data suggest potential ways to mitigate health care profession trainee challenges that can follow a crisis like the COVID-19 pandemic, although further study is warranted.

While narrative responses with pandemic-related keywords did indicate challenges specific to COVID-19 (ie, limited access to workspaces and/or computers equipped for telehealth), the overall frequency of pandemic-related responses was low. This may indicate these are institutional challenges trainees face independent of the pandemic. These findings warrant longterm attention to the satisfaction of psychology and social worker trainees’ during the pandemic. For example, additional training for the use of telehealth could be provided. One study indicated that < 61% of psychology postdoctoral fellows received telepsychology training during the pandemic, and of those who did receive training, less than half were satisfied with it.³

Similarly, strategies could be developed to ensure a more supportive learning and work environment, and provide additional networking opportunities for trainees, despite social distancing. Education specific to disaster response should be incorporated into behavioral health care professionals’ training, especially because behavioral health care professionals provided major contributions during the pandemic due to reported increases in mental health concerns (eg, anxiety and depression) during the period.^7,17,18 As the pandemic progressed, policies and procedures were established or modified to address some of these concerns because they were not necessarily limited to trainees. For example, additional training resources were developed to support the use of various telehealth technologies, virtual resources were used more often for meetings, and supervisors developed more comfort and familiarity with how to manage in a virtual or hybrid environment.

Limitations

Although the TSS data provide a large national sample of behavioral health care trainees, it only includes VA trainees, and therefore may not be completely generalizable across health care. However, because many psychologists and social workers throughout the US train at the VA, and because the VA is the largest employer of practicing psychologists and social workers, understanding the impacts felt at the VA informs institutions nationally.^8-11 The TSS has limited demographic data (eg, age, race, ethnicity, and sex), so it is unclear whether the respondent groups before and during the pandemic differed in ways that could relate to outcomes. The data also do not specify exact training dates; however, anecdotal evidence suggests respondents generally complete the survey close to the end of their training.

Additionally, open-ended narrative responses were only asked for replies that indicated dissatisfaction, precluding a more nuanced understanding of potential positive outcomes. Furthermore, the TSS is limited to questions about the trainees’ clinical experiences, but because the pandemic created many stressors, there may have been personal issues that affected their work. It is possible that changes in overall satisfaction may have been rooted in something outside of their clinical experience. Finally, the response rate for the TSS is consistently low both before and during the pandemic and includes a limited number of narrative responses.

CONCLUSIONS

The VA is an important contributor to the education, training, and composition of the behavioral health care workforce. A deeper understanding of the VA trainee experience is important to identify how to improve behavioral health care professional education and training. This is especially true as behavioral health care faces shortages within the VA and nationwide.^8,12,19

This study reinforces research that found health care trainees experienced decreased learning opportunities and telehealth-related challenges during the COVID-19 pandemic. ^13,20 Despite the observed decline in trainee satisfaction, the lack of a corresponding change in likelihood to seek employment with the VA is encouraging for VA efforts to maintain and grow its behavioral health care workforce and for similar efforts outside VA. This resilience may relate to the substantial prepandemic time invested in their professional development. Future studies should examine long term impacts of the pandemic on trainee’s clinical experience and whether the pipeline of behavioral health care workers declines over time as students that are earlier in their career paths instead chose other professions. Future research should also explore ways to improve professional development and wellness of behavioral health care trainees during disasters (eg, telehealth training, additional networking, and social support).

The COVID-19 pandemic changed the education and training experiences of health care students and those set to comprise the future workforce. Apart from general training disruptions or delays due to the pandemic, behavioral health trainees such as psychologists and social workers faced limited opportunities to provide in-person services.^1-5 Trainees also experienced fewer referrals to mental health services from primary care and more disrupted, no-show, or cancelled appointments.^4-6 Behavioral health trainees experienced a limited ability to establish rapport and more difficulty providing effective services because of the limited in-person interaction presented by telehealth.⁶ The pandemic also resulted in feelings of increased isolation and decreased teamwork.^1,7 The virtual or remote setting made it more difficult for trainees to feel as if they were a member of a team or community of behavioral health professionals.^1,7

Behavioral health trainees had to adapt to conducting patient visits and educational didactics through virtual platforms.^1,3-7 Challenges included access or technological problems with online platforms and a lack of telehealth training use.^3,4,6 One study found that while both behavioral health trainees and licensed practitioners reported similar rates of telehealth use for mental health services by early April 2020, trainees had more difficulties implementing telehealth compared with licensed practitioners. This study found that US Department of Veteran Affairs (VA) facilities reported higher use of telehealth in February 2020.⁵

A mission of the VA is to provide education and training to health care professionals through partnerships with affiliated academic institutions. The VA is the largest education and training supplier for health care professions in the US. As many as 50% of psychologists in the US received some training at the VA.⁸ Additionally, more graduate-level social work students are trained at the VA than at any other organization.⁹ The VA is a major contributor to not only its own behavioral health workforce, but that of the entire country.

The VA is also the largest employer of psychologists and social workers in the US.^10,11 The VA Office of Academic Affiliations (OAA) oversees health care profession education and training at all VA facilities. In 2012, OAA began the Mental Health Education Expansion program to increase training for behavioral health professionals, including psychologists and social workers. ¹² The OAA initiative was aligned with VA training and workforce priorities.^8,12 To gauge the effectiveness of VA education and training, OAA encourages VA trainees to complete the Trainee Satisfaction Survey (TSS), which measures trainee satisfaction and the likelihood of a trainee to consider the VA for future employment.

Researchers at the Veterans Emergency Management Evaluation Center sought to understand the impact the COVID-19 pandemic had on behavioral health trainees’ experiences by examining TSS data from before and after the onset of the pandemic. This study expands on prior research among physician residents and fellows which found associations between VA training experiences and the COVID- 19 pandemic. The previous study found declines in trainee satisfaction and a decreased likelihood to consider the VA for future employment.¹³

It is important to understand the effects the pandemic had on the professional development and wellness for both physician and behavioral health professional trainees. Identifying how the pandemic impacted trainee satisfaction may help improve education programs and mitigate the impact of future public health emergencies. This is particularly important due to the shortage of behavioral health professionals in the VA and the US.^12,14

METHODS

This study used TSS data collected from August 2018 to July 2021 from 153 VA facilities. A behavioral health trainee was defined as any psychology or social work trainee who completed 1 rotation at a VA facility. Psychiatric trainees were excluded because as physicians their training programs differ markedly from those for psychology and social work. Excluding psychiatry, psychology and social work comprise the 2 largest mental health care training groups.

This study was reviewed and approved as a quality improvement project by the VA Greater Los Angeles Healthcare System (VAGLAHS) Institutional Review Board, which waived informed consent requirements. The OAA granted access to data using a process open to all VA researchers. At the time of data collection, respondents were assured their anonymity; participation was voluntary.

Measures

Any response provided before February 29, 2020, was defined as the prepandemic period. The pandemic period included any response from April 1, 2020, to July 31, 2021. Responses collected in March 2020 were excluded as it would be unclear from the survey whether the training period occurred before or after the onset of the pandemic.

To measure overall trainee satisfaction with the VA training experience, responses were grouped as satisfied (satisfied/ very satisfied) and dissatisfied (dissatisfied/ very dissatisfied). To measure a trainee’s likelihood to consider the VA for future employment as a result of their training experience, responses were grouped as likely (likely/very likely) and unlikely (unlikely/very unlikely).

Other components of satisfaction were also collected including onboarding, clinical faculty/preceptors, clinical learning environment, physical environment, working environment, and respect felt at work. If a respondent chose very dissatisfied or dissatisfied, they were subsequently asked to specify the reason for their dissatisfaction with an open-ended response. Open-ended responses were not permitted if a respondent indicated a satisfied or very satisfied response.

Statistical Analyses

Stata SE 17 was used for statistical analyses. To test the relationship between the pandemic group and the 2 separate outcome variables, logistic regressions were conducted to measure overall satisfaction and likelihood of future VA employment. Margin commands were used to calculate the difference in the probability of reporting satisfied/very satisfied and likely/very likely for the prepandemic and pandemic groups. The association of the COVID-19 group with each outcome variable was expressed as the difference in the percentage of the outcome between the prepandemic and pandemic groups. Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees; therefore, the groups were combined.

Rapid Coding and Thematic Analyses

Qualitative data were based on open-ended responses from behavioral health trainees when they were asked to specify the cause of dissatisfaction in the aforementioned areas of satisfaction. Methods for qualitative data included rapid coding and thematic content analyses.^15,16 Additional general information regarding the qualitative data analyses is described elsewhere.¹³ A keyword search was completed to identify all open-ended responses related to COVID-19 pandemic causes of dissatisfaction. Keywords included: virus, COVID, corona, pandemic, PPE, N95, mask, social distance, and safety. All open-ended responses were reviewed to ensure keywords were appropriately identifying pandemic-related causes of dissatisfaction and did not overlook other references to the pandemic, and to identify initial themes and corresponding definitions based on survey questions. After review, additional keywords were included in the content analyses that were related to providing mental health services using remote or telehealth options. This included the following keywords: remote, video, VVC (VA Video Connect), and tele. The research team completed a review of the initial themes and definitions and created a final coding construct with definitions before completing an independent coding of all identified pandemic-related responses. Frequency counts of each code were provided to identify which pandemic-related causes of dissatisfaction were mentioned most.

RESULTS

A total of 3950 behavioral health trainees responded to the TSS, including 2715 psychology trainees and 1235 social work trainees who indicated they received training at the VA in academic years 2018/2019, 2019/2020, or 2020/2021. The academic year 2018/2019 was considered in an effort to provide a larger sample of prepandemic trainees.

The percentage of trainees reporting satisfaction with their training decreased across prepandemic to pandemic groups. In the pandemic group, 2166 of 2324 respondents (93.2%) reported satisfaction compared to 1474 of 1555 (94.8%) in the prepandemic trainee group (P = .04; 95% CI, -3.10 to -0.08). There was no association between the pandemic group and behavioral health trainees’ reported willingness to consider the VA for future employment (Table 1). Preliminary analyses demonstrated similar effects of the pandemic on psychology and social work trainees, therefore the groups were combined, and overall effects were reported.

Pandemic-Related Dissatisfaction

Of the 3950 psychology and social work trainees who responded to the survey, 75 (1.9%) indicated dissatisfaction with their VA training experience using pandemic-related keywords. Open-ended responses were generally short (range, 1-32 words; median, 19 words). Qualitative analyses revealed 7 themes (Table 2).

The most frequently identified theme was challenges with onboarding. One respondent indicated the modified onboarding procedures in place due to the pandemic were difficult to understand and resulted in delays. Another frequently mentioned cause of dissatisfaction was limited work or office space and insufficient computer availability. This was often noted to relate to a lack of private space to conduct telehealth visits or computers that were not equipped to provide telehealth. Several respondents also noted technological issues when attempting to use VVC to provide telehealth.

Another common theme was that the pandemic diminished teamwork, generated feelings of isolation, and created unsupportive environments for trainees. For instance, some trainees indicated that COVID-19 decreased the inclusion of trainees as part of the regular staff groups and accordingly resulted in limited networking opportunities. Other causes of dissatisfaction included the pandemic’s impacts on the learning environment, such as decreases in patient volume, decreased diversity of patient cases, and a limited presence of faculty mentors. Several respondents indicated that the pandemic limited their caseloads and indicated that most patients were seen virtually. Open-ended responses from a few respondents indicated their training environments were noncompliant with social distancing, personal protective equipment requirements, or other safety guidelines.

DISCUSSION

This study illustrates the impact of the COVID-19 pandemic on the behavioral health trainee experience, which was expressed through decreased satisfaction with their clinical training at the VA. The narrative data indicated that the observed pandemic-related dissatisfaction was linked specifically to onboarding, a lack of safe and private workspaces and computers, as well as a lack of a supportive work environment.

Although the reported decrease in satisfaction was statistically significant, the effect size was not large. Additionally, while satisfaction did decrease, the trainees’ reported likelihood to consider the VA for future employment was not impacted. This may suggest psychologist and social work trainees’ perseverance and dedication to their chosen profession persisted despite the challenges presented by the pandemic. Furthermore, the qualitative data suggest potential ways to mitigate health care profession trainee challenges that can follow a crisis like the COVID-19 pandemic, although further study is warranted.

While narrative responses with pandemic-related keywords did indicate challenges specific to COVID-19 (ie, limited access to workspaces and/or computers equipped for telehealth), the overall frequency of pandemic-related responses was low. This may indicate these are institutional challenges trainees face independent of the pandemic. These findings warrant longterm attention to the satisfaction of psychology and social worker trainees’ during the pandemic. For example, additional training for the use of telehealth could be provided. One study indicated that < 61% of psychology postdoctoral fellows received telepsychology training during the pandemic, and of those who did receive training, less than half were satisfied with it.³

Similarly, strategies could be developed to ensure a more supportive learning and work environment, and provide additional networking opportunities for trainees, despite social distancing. Education specific to disaster response should be incorporated into behavioral health care professionals’ training, especially because behavioral health care professionals provided major contributions during the pandemic due to reported increases in mental health concerns (eg, anxiety and depression) during the period.^7,17,18 As the pandemic progressed, policies and procedures were established or modified to address some of these concerns because they were not necessarily limited to trainees. For example, additional training resources were developed to support the use of various telehealth technologies, virtual resources were used more often for meetings, and supervisors developed more comfort and familiarity with how to manage in a virtual or hybrid environment.

Limitations

Although the TSS data provide a large national sample of behavioral health care trainees, it only includes VA trainees, and therefore may not be completely generalizable across health care. However, because many psychologists and social workers throughout the US train at the VA, and because the VA is the largest employer of practicing psychologists and social workers, understanding the impacts felt at the VA informs institutions nationally.^8-11 The TSS has limited demographic data (eg, age, race, ethnicity, and sex), so it is unclear whether the respondent groups before and during the pandemic differed in ways that could relate to outcomes. The data also do not specify exact training dates; however, anecdotal evidence suggests respondents generally complete the survey close to the end of their training.

Additionally, open-ended narrative responses were only asked for replies that indicated dissatisfaction, precluding a more nuanced understanding of potential positive outcomes. Furthermore, the TSS is limited to questions about the trainees’ clinical experiences, but because the pandemic created many stressors, there may have been personal issues that affected their work. It is possible that changes in overall satisfaction may have been rooted in something outside of their clinical experience. Finally, the response rate for the TSS is consistently low both before and during the pandemic and includes a limited number of narrative responses.

CONCLUSIONS

The VA is an important contributor to the education, training, and composition of the behavioral health care workforce. A deeper understanding of the VA trainee experience is important to identify how to improve behavioral health care professional education and training. This is especially true as behavioral health care faces shortages within the VA and nationwide.^8,12,19

This study reinforces research that found health care trainees experienced decreased learning opportunities and telehealth-related challenges during the COVID-19 pandemic. ^13,20 Despite the observed decline in trainee satisfaction, the lack of a corresponding change in likelihood to seek employment with the VA is encouraging for VA efforts to maintain and grow its behavioral health care workforce and for similar efforts outside VA. This resilience may relate to the substantial prepandemic time invested in their professional development. Future studies should examine long term impacts of the pandemic on trainee’s clinical experience and whether the pipeline of behavioral health care workers declines over time as students that are earlier in their career paths instead chose other professions. Future research should also explore ways to improve professional development and wellness of behavioral health care trainees during disasters (eg, telehealth training, additional networking, and social support).