Federal Practitioner

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

A version of this story first appeared on Medscape.com.

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

A version of this story first appeared on Medscape.com.

Mild asthma is not benign. Underdiagnosis in children exposes them to preventable morbidity — including impaired lung growth that can lead to fixed airway obstruction and a higher lifetime risk for chronic obstructive pulmonary disease (COPD), as well as severe exacerbations and increased need for systemic corticosteroids. Experts at the 21st Francophone Allergy Congress 2026 said preserving respiratory function depends on early diagnosis and disease control.

Mild asthma is retrospectively defined as the level of treatment required to achieve and maintain disease control. It corresponds to asthma controlled with a low dose of inhaled corticosteroids or with a combination of inhaled corticosteroids and formoterol as needed (Global Initiative for Asthma(GINA)/French Society of Pediatric Pulmonology and Allergology, steps 1-2).

Mélisande Bourgoin-Heck, MD, PhD, Department of Pediatric Allergology, Armand Trousseau University Hospital, Sorbonne University, AP-HP, Paris, France, emphasized a fundamental distinction: “While control is based on symptoms, exacerbations, activity limitations, and quality of life, severity corresponds to the level of treatment required to achieve this control. The term mild therefore depends on the treatment required and not solely on the frequency or intensity of symptoms.”

How to Identify It?

Clinically, asthma most often presents with wheezing, cough, shortness of breath, and chest tightness, with symptoms that fluctuate in frequency and severity. Nighttime symptoms are common. Symptoms often start or worsen with viral infections, physical exertion (including after exercise), laughter, or exposure to allergens or cold air. “Symptoms are often dismissed as minor and intermittent,” the pediatrician said, “which leads to delayed diagnosis.”

That’s why recognizing risk factors is important because they help guide diagnosis: male sex, a first-degree family history of asthma, exposure to secondhand smoke, prematurity, maternal obesity, living in group settings or having school-aged siblings which raise the risk for early infections, a history of severe bronchiolitis, and an atopic tendency, demonstrated by atopic dermatitis, allergic rhinitis, or sensitization to food and respiratory allergens.

How Much Should We Trust Predictive Scores?

Several clinical scores for predicting asthma exist, notably the Asthma Predictive Index, the modified Asthma Predictive Index, and the Pediatric Asthma Risk Score; the latter demonstrates better overall discrimination, making it useful for children at low-to-moderate risk.

“These scores place significant emphasis on the atopic predisposition,” noted Bourgoin-Heck, “including allergic sensitivities, allergic rhinitis, and atopic dermatitis. Their performance varies by age and clinical phenotype. They are highly specific for the diagnosis of allergic asthma, with a positive score associated with a high risk of asthma. However, their sensitivity is not up to par: A negative score does not rule out the diagnosis, leading to a risk of overlooking nonallergic forms.”

A chest x-ray is used to rule out differential diagnoses. It may be normal or reveal chest distension or bronchial signs. During follow-up, it is only recommended in cases of fever or severe illness to look for complications such as bronchopulmonary superinfection, pneumothorax, pneumomediastinum, subcutaneous emphysema and ventilation disorders/atelectasis.

Normal Spirometry: Could Asthma Really be Ruled Out?

Pulmonary function tests (PFTs) may be normal and do not rule out asthma. Spirometry can be performed around age 6 years and is often normal. “The reversibility test is a diagnostic indicator but may be negative in cases of normal forced expiratory volume in 1 second (FEV₁),” warned the specialist.

Provocation tests are useful in cases of doubt.

In children unable to perform a forced exhalation, spirometry is impossible or unreliable, which justifies the use of respiratory resistance measurements (starting at age 3). Several methods are then used: flow-interruption resistance (FIR) identifies bronchial obstruction with an expiratory FIR > 2 Z scores (how many SDs a result is from the predicted value for a child’s age/height/sex). Oscillometry, suitable for young children, is considered pathologic for values exceeding 150% of the predicted value. Plethysmography indicates obstruction with a Raw value > 150% of the predicted value or an sRaw value > 180%.

Interpretation is based on standards adapted to the technique and the study population, with thresholds varying by method (threshold values for PFTs, page e4).

When in Doubt, How Useful Are Biomarkers?

As a biomarker of atopy, a blood eosinophil count of at least 150/mm³ is associated with asthma symptoms and exacerbations. Specific Immunoglobulin E (IgE) indicates allergic sensitization associated with asthma. Finally, elevated fractional concentration of exhaled nitric oxide (> 20-25 parts per billion depending on age) is associated with wheezing, corticosteroid use, and persistent asthma. The combination of atopy markers — including maternal allergy, eczema, wheezing, positive specific IgE levels, and eosinophilia — significantly increases the likelihood of asthma.

“However, when diagnostic uncertainty persists in a child younger than 5 years (absence of atopy; normal PFTs — which is common), a trial of treatment based on initial symptoms may be recommended according to GINA 2025 (Box 10-2),” explained Bourgoin-Heck.

In the presence of mild and intermittent symptoms, a short-acting bronchodilator challenge test on demand is indicated for a maximum duration of 2-3 months. This strategy applies to infrequent wheezing episodes, without the need for emergency care and therefore without any severe exacerbations, with symptoms occurring twice or less per week. Treatment consists of administering two puffs when symptoms occur (to be repeated as needed), with an assessment of improvement within 20-60 minutes. In cases of a history of a severe wheezing episode within the past year (systemic corticosteroids, emergency department visit, and hospitalization) or symptoms more than twice a week, the therapeutic trial involves long-term inhaled corticosteroids (eg, fluticasone 100 µg/d to 250 µg/d) combined with a short-acting bronchodilator as needed for 2-3 months. If the response is favorable, treatment is adjusted to the minimum effective dose.

Monitoring of clinical progress relies on asthma control scores such as the Asthma Control Test, considering both parental perception and the child’s self-assessment. Because the goal in mild asthma is indeed to achieve complete control.

Mild Asthma: Behind the Triviality, Real Risks

Mild childhood asthma is the most common form of asthma. It is by no means benign and carries a risk for exacerbations requiring systemic corticosteroids and potential long-term consequences.

Asthma is often missed — an estimated 20% of children age ≥ 6 years to 70% by age 1 year are not identified — and therefore go untreated, leading to a lower quality of life from attacks and persistent symptoms between episodes that could limit activity and disrupt sleep.

Even seemingly mild asthma is associated with a risk for severe exacerbation, including in patients with infrequent and mild symptoms.

There is also impaired lung growth, with a decrease in peak lung function and the potential for progression to fixed bronchial obstruction, which can lead to COPD. However, it has been shown that early treatment reduces chronic inflammation, limits bronchial remodeling, and prevents the decline in lung function.

In a Danish neonatal cohort 9125 infants, were followed at 1, 3, and 6 years of age and analyzed at 50 years of age via the Danish COPD patient registry, early asthma symptoms were associated with a decrease in FEV1 (-3.36%) and the FEV1/ Forced Vital Capacity ratio (-1.28), as well as an increased risk for a COPD diagnosis in adulthood (odds ratio [OR], 1.96).

Epidemiologic data confirm this: A history of asthma increases the risk of developing COPD by 10-30 times, and a reduced peak FEV1 in early adulthood is associated with an increased risk for early‑onset COPD and greater severity.

“Asthma is associated with a decline in lung function that can begin as early as infancy,” noted the pediatrician, “or even during the prenatal period, persists throughout childhood, continues into adulthood, and predisposes individuals to established bronchial obstruction.”

Early Inhaled Corticosteroids Reduced Exacerbations

In the inhaled steroid treatment as regular therapy in early asthma trial, which enrolled about 7000 adults and children and included a subgroup of 1900 children aged < 11 years with recent-onset mild asthma, inhaled budesonide was compared with placebo. Over 3 years of follow-up, the placebo group showed poorer lung function, whereas those treated with budesonide had improved FEV1 and about a 40% reduction in severe exacerbations. A partial functional “catch-up” was observed when treatment was initiated in the third year.

However, the study does not allow for conclusions regarding the very long-term prevention of functional decline, due to the lack of sufficient follow-up time.

Delayed Treatment Increases Risks

Furthermore, delayed treatment is associated with an increased use of short-acting bronchodilators and systemic corticosteroids, carrying a risk for complications. The specialist warned: “Adverse effects appear after just a few courses of oral corticosteroids, notably an increased risk of fractures (odds ratio, 2.15 for low doses of prednisolone < 70 mg; OR, 3.09 for higher doses > 70 mg). These risks are real and emerge quickly.”

Another study confirms the adverse effects of oral corticosteroid therapy: A cumulative dose of 500 mg to 1000 mg (approximately four to five courses of systemic corticosteroids over a lifetime) already increases the risk. Complications include osteoporosis, diabetes, cataracts, heart failure, and pneumonia. “Cumulative exposure, even intermittent, is associated with increased morbidity, which can be prevented through appropriate management of mild asthma,” she added. “Yet it has been clearly demonstrated that inhaled therapy reduces the need for oral corticosteroids.”

This story was translated from Medscape’s French edition.

A version of this story first appeared on Medscape.com.

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

Military veterans exposed to burn pits during deployment are > 4 times higher risk for persistent cough and 3 times higher risk for dyspnea and wheezing compared with unexposed veterans. Following clinical evaluation, nearly half of veterans received diagnoses of respiratory diseases, including asthma (about 30%), chronic obstructive pulmonary disease (about 13%), and bronchitis (about 12%). Diagnostic uncertainty remains common, with nearly one-third of symptomatic veterans still lacking a specific diagnosis after extensive noninvasive testing.

METHODOLOGY:

• Focused review that proposed an assessment and monitoring strategy for deployed US military veterans with unexplained dyspnea that incorporates multidisciplinary review and patient discussion.
• Analysis included data from the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE), which evaluated respiratory symptoms in military personnel within 6 months of returning from Southwest Asia.
• Registry and survey input included Airborne Hazards and Open Burn Pit Registry clinical evaluations in 24,578 veterans in addition to a survey of 479 veterans.
• Biopsy guidance emphasized case-by-case decisions after review; supporting examples include 49 symptomatic veterans undergoing high-resolution computed tomography in STAMPEDE and 38 veterans with biopsy-proven constrictive bronchiolitis, many with normal or near normal pulmonary function tests (PFTs).

TAKEAWAY: 

• Veterans with persistent unexplained cough, dyspnea, or chest tightness for > 3 months, reduced exercise tolerance, or abnormal PFTs should be referred to a pulmonary specialist for diagnostic evaluation.
• Among 380 military personnel with chronic respiratory symptoms in STAMPEDE III, 22.9% had diagnoses of asthma, 15.0% had airway hyperreactivity, 10.8% had upper and large airways disorders, and 32.0% did not meet criteria for a specific diagnosis after extensive noninvasive testing.
• Standard testing can miss disease: among 38 veterans with biopsy-proven constrictive bronchiolitis, 19 had normal or near normal PFTs compared with the general population, despite reductions vs a historical asymptomatic military cohort.
• Long-term management centers on follow-up, with proposed PFT monitoring every 6 to 12 months in symptomatic patients even when initial findings are normal.

IN PRACTICE:

“Significant gaps remain in the provision of health care and benefits,” the authors wrote. “The assessment of veterans with suspected lung disease should be comprehensive, involving a thorough medical and exposure history, as well as PFTs and imaging.

SOURCE:

The study was led by Robert M. Tighe, MD, Duke University Medical Center in Durham, North Carolina; Le Roy Torres, Burn Pits 360 in Robstown, Texas; and Robert Miller, Vanderbilt University Medical Center in Nashville, Tennessee. It was published online in Annals of the American Thoracic Society.

LIMITATIONS:

This article synthesizes existing literature and expert recommendations without presenting new primary data or statistical analyses. The review acknowledges that diagnosing deployment-related respiratory disorders can be challenging as symptoms are often nonspecific and may present months or years after deployment with variable latency. The current Post-Deployment Cardiopulmonary Evaluation Network structure does not have the capacity to evaluate the large number of veterans with respiratory disorders and is limited to those who have registered symptoms through the Airborne Hazards and Open Burn Pit Registry.

DISCLOSURES:

Writing support was provided by Julie Fleming and Wendy Morris of Fleishman-Hillard, which was contracted and funded by Boehringer Ingelheim Pharmaceuticals. Boehringer Ingelheim was given the opportunity to review the article for medical and scientific accuracy as well as intellectual property considerations. No disclosures or conflict of interest statements for the individual authors are provided in the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

A few days of fasting around chemotherapy sessions may improve treatment response and outcomes for some patients with advanced ovarian cancer, a small phase 2 trial suggests.

The study, of 36 patients with stage III or IV high-grade ovarian cancer, found that those randomly assigned to fast for 36 hours before chemotherapy and 24 hours afterward had stronger pathologic responses to chemotherapy and longer progression-free survival than patients who ate normally during treatment.

The findings, reported at a press briefing ahead the American Society of Clinical Oncology (ASCO) 2026, hint at a straightforward measure to potentially improve patients’ outcomes.

The working theory is that short-term fasting boosts chemotherapy response by lowering insulin and IGF-1 levels, both of which are implicated in tumor growth and chemotherapy resistance, said study presenter Claudia Marchetti, MD, of Agostino Gemelli University in Rome, Italy.

Speaking at the briefing, ASCO President Eric Small, MD, of the University of California San Francisco, called the study “a great example of a very simple intervention that has benefit and can be undertaken and implemented anywhere in the world.”

“It’s not an expensive new drug,” he said, “and yet it has the potential to really have an impact on this cancer.”

Ovarian cancer affects more than 324,000 women worldwide each year and causes more than 206,000 deaths annually. Around 80% of patients are diagnosed at an advanced stage, and up to 60% receive neoadjuvant chemotherapy to reduce tumor size and facilitate surgery.

Despite advances in surgery and chemotherapy, patients with advanced disease still face poor outcomes. There is, Marchetti said, “an urgent need for safe, low-cost, and easily implementable strategies that can enhance treatment efficacy and improve patient prognosis.”

Given evidence on the role of insulin in tumor growth and chemotherapy response, her team hypothesized that short bouts of fasting around the time of treatment might have benefits.

To test that idea, the researchers recruited 36 patients with newly diagnosed stage III or IV high-grade serous ovarian carcinoma who were not candidates for primary cytoreduction. All were in good general health, with a mean age of 62 years.

All patients received 3 rounds of carboplatin and paclitaxel before surgery. Prior to starting chemotherapy, half were randomly assigned to fast for 36 hours before and 24 hours after chemotherapy, whereas the other half ate normally throughout treatment.

Patients in the fasting group consumed no more than 350 calories per day during the fasting window. They were allowed to have unrestricted water, herbal tea, limited vegetable juice, and small amounts of light vegetable broth. (A ketogenic diet group had initially been planned but was closed early because of poor patient compliance.)

The study met its primary endpoint of change in insulin levels during chemotherapy, Marchetti reported. Baseline insulin levels were comparable between the 2 groups, but after 3 rounds of chemotherapy, they’d dipped by an average of 1.12 µIU/mL in the fasting group and increased by 9.76 µIU/mL in the control group (P = .01).

Fasting also improved clinical outcomes. Specifically, Marchetti said, 59% of fasting patients achieved a chemotherapy response score of 3 — indicating complete or near-complete tumor response before surgery — compared with 17% of patients in the control group.

Median progression-free survival was significantly longer in the fasting group, at 38 vs 24 months.

Importantly, Marchetti said, the fasting protocol was feasible, well tolerated, and safe: All patients assigned to the fasting group completed treatment, and rates of chemotherapy-related toxicities were similar between the 2 groups.

Additional analyses shed more light on the possible mechanisms underlying the fasting group’s improved outcomes: The researchers found that those patients tended to have lower levels of circulating suppressor granulocyte and monocyte populations that have been linked to tumor immune escape, which suggests, Marchetti said, fasting may have set the stage for a “more favorable immune environment” during chemotherapy.

However, she cautioned that much more research is needed. Her team is planning a larger multicenter trial to validate the current findings, and longer-term follow-up is necessary to see whether fasting ultimately impacts patients’ survival, Marchetti said.

In a statement, Eleonora Teplinsky, MD, an ASCO expert in gynecologic cancers, said these early findings are “encouraging, support earlier data, and highlight a promising area of cancer research.”

But she, too, emphasized the need for larger clinical trials to build on the results.

The study had no commercial funding. Marchetti disclosed having relationships with Arquer Diagnostics, AstraZeneca, Clovis Oncology, and other companies. Small disclosed having relationships with Janssen, Johnson & Johnson, and others. Teplinsky had no disclosures.

A version of this article first appeared on Medscape.com.

A few days of fasting around chemotherapy sessions may improve treatment response and outcomes for some patients with advanced ovarian cancer, a small phase 2 trial suggests.

The study, of 36 patients with stage III or IV high-grade ovarian cancer, found that those randomly assigned to fast for 36 hours before chemotherapy and 24 hours afterward had stronger pathologic responses to chemotherapy and longer progression-free survival than patients who ate normally during treatment.

The findings, reported at a press briefing ahead the American Society of Clinical Oncology (ASCO) 2026, hint at a straightforward measure to potentially improve patients’ outcomes.

The working theory is that short-term fasting boosts chemotherapy response by lowering insulin and IGF-1 levels, both of which are implicated in tumor growth and chemotherapy resistance, said study presenter Claudia Marchetti, MD, of Agostino Gemelli University in Rome, Italy.

Speaking at the briefing, ASCO President Eric Small, MD, of the University of California San Francisco, called the study “a great example of a very simple intervention that has benefit and can be undertaken and implemented anywhere in the world.”

“It’s not an expensive new drug,” he said, “and yet it has the potential to really have an impact on this cancer.”

Ovarian cancer affects more than 324,000 women worldwide each year and causes more than 206,000 deaths annually. Around 80% of patients are diagnosed at an advanced stage, and up to 60% receive neoadjuvant chemotherapy to reduce tumor size and facilitate surgery.

Despite advances in surgery and chemotherapy, patients with advanced disease still face poor outcomes. There is, Marchetti said, “an urgent need for safe, low-cost, and easily implementable strategies that can enhance treatment efficacy and improve patient prognosis.”

Given evidence on the role of insulin in tumor growth and chemotherapy response, her team hypothesized that short bouts of fasting around the time of treatment might have benefits.

To test that idea, the researchers recruited 36 patients with newly diagnosed stage III or IV high-grade serous ovarian carcinoma who were not candidates for primary cytoreduction. All were in good general health, with a mean age of 62 years.

All patients received 3 rounds of carboplatin and paclitaxel before surgery. Prior to starting chemotherapy, half were randomly assigned to fast for 36 hours before and 24 hours after chemotherapy, whereas the other half ate normally throughout treatment.

Patients in the fasting group consumed no more than 350 calories per day during the fasting window. They were allowed to have unrestricted water, herbal tea, limited vegetable juice, and small amounts of light vegetable broth. (A ketogenic diet group had initially been planned but was closed early because of poor patient compliance.)

The study met its primary endpoint of change in insulin levels during chemotherapy, Marchetti reported. Baseline insulin levels were comparable between the 2 groups, but after 3 rounds of chemotherapy, they’d dipped by an average of 1.12 µIU/mL in the fasting group and increased by 9.76 µIU/mL in the control group (P = .01).

Fasting also improved clinical outcomes. Specifically, Marchetti said, 59% of fasting patients achieved a chemotherapy response score of 3 — indicating complete or near-complete tumor response before surgery — compared with 17% of patients in the control group.

Median progression-free survival was significantly longer in the fasting group, at 38 vs 24 months.

Importantly, Marchetti said, the fasting protocol was feasible, well tolerated, and safe: All patients assigned to the fasting group completed treatment, and rates of chemotherapy-related toxicities were similar between the 2 groups.

Additional analyses shed more light on the possible mechanisms underlying the fasting group’s improved outcomes: The researchers found that those patients tended to have lower levels of circulating suppressor granulocyte and monocyte populations that have been linked to tumor immune escape, which suggests, Marchetti said, fasting may have set the stage for a “more favorable immune environment” during chemotherapy.

However, she cautioned that much more research is needed. Her team is planning a larger multicenter trial to validate the current findings, and longer-term follow-up is necessary to see whether fasting ultimately impacts patients’ survival, Marchetti said.

In a statement, Eleonora Teplinsky, MD, an ASCO expert in gynecologic cancers, said these early findings are “encouraging, support earlier data, and highlight a promising area of cancer research.”

But she, too, emphasized the need for larger clinical trials to build on the results.

The study had no commercial funding. Marchetti disclosed having relationships with Arquer Diagnostics, AstraZeneca, Clovis Oncology, and other companies. Small disclosed having relationships with Janssen, Johnson & Johnson, and others. Teplinsky had no disclosures.

A version of this article first appeared on Medscape.com.

A few days of fasting around chemotherapy sessions may improve treatment response and outcomes for some patients with advanced ovarian cancer, a small phase 2 trial suggests.

The study, of 36 patients with stage III or IV high-grade ovarian cancer, found that those randomly assigned to fast for 36 hours before chemotherapy and 24 hours afterward had stronger pathologic responses to chemotherapy and longer progression-free survival than patients who ate normally during treatment.

The findings, reported at a press briefing ahead the American Society of Clinical Oncology (ASCO) 2026, hint at a straightforward measure to potentially improve patients’ outcomes.

The working theory is that short-term fasting boosts chemotherapy response by lowering insulin and IGF-1 levels, both of which are implicated in tumor growth and chemotherapy resistance, said study presenter Claudia Marchetti, MD, of Agostino Gemelli University in Rome, Italy.

Speaking at the briefing, ASCO President Eric Small, MD, of the University of California San Francisco, called the study “a great example of a very simple intervention that has benefit and can be undertaken and implemented anywhere in the world.”

“It’s not an expensive new drug,” he said, “and yet it has the potential to really have an impact on this cancer.”

Ovarian cancer affects more than 324,000 women worldwide each year and causes more than 206,000 deaths annually. Around 80% of patients are diagnosed at an advanced stage, and up to 60% receive neoadjuvant chemotherapy to reduce tumor size and facilitate surgery.

Despite advances in surgery and chemotherapy, patients with advanced disease still face poor outcomes. There is, Marchetti said, “an urgent need for safe, low-cost, and easily implementable strategies that can enhance treatment efficacy and improve patient prognosis.”

Given evidence on the role of insulin in tumor growth and chemotherapy response, her team hypothesized that short bouts of fasting around the time of treatment might have benefits.

To test that idea, the researchers recruited 36 patients with newly diagnosed stage III or IV high-grade serous ovarian carcinoma who were not candidates for primary cytoreduction. All were in good general health, with a mean age of 62 years.

All patients received 3 rounds of carboplatin and paclitaxel before surgery. Prior to starting chemotherapy, half were randomly assigned to fast for 36 hours before and 24 hours after chemotherapy, whereas the other half ate normally throughout treatment.

Patients in the fasting group consumed no more than 350 calories per day during the fasting window. They were allowed to have unrestricted water, herbal tea, limited vegetable juice, and small amounts of light vegetable broth. (A ketogenic diet group had initially been planned but was closed early because of poor patient compliance.)

The study met its primary endpoint of change in insulin levels during chemotherapy, Marchetti reported. Baseline insulin levels were comparable between the 2 groups, but after 3 rounds of chemotherapy, they’d dipped by an average of 1.12 µIU/mL in the fasting group and increased by 9.76 µIU/mL in the control group (P = .01).

Fasting also improved clinical outcomes. Specifically, Marchetti said, 59% of fasting patients achieved a chemotherapy response score of 3 — indicating complete or near-complete tumor response before surgery — compared with 17% of patients in the control group.

Median progression-free survival was significantly longer in the fasting group, at 38 vs 24 months.

Importantly, Marchetti said, the fasting protocol was feasible, well tolerated, and safe: All patients assigned to the fasting group completed treatment, and rates of chemotherapy-related toxicities were similar between the 2 groups.

Additional analyses shed more light on the possible mechanisms underlying the fasting group’s improved outcomes: The researchers found that those patients tended to have lower levels of circulating suppressor granulocyte and monocyte populations that have been linked to tumor immune escape, which suggests, Marchetti said, fasting may have set the stage for a “more favorable immune environment” during chemotherapy.

However, she cautioned that much more research is needed. Her team is planning a larger multicenter trial to validate the current findings, and longer-term follow-up is necessary to see whether fasting ultimately impacts patients’ survival, Marchetti said.

In a statement, Eleonora Teplinsky, MD, an ASCO expert in gynecologic cancers, said these early findings are “encouraging, support earlier data, and highlight a promising area of cancer research.”

But she, too, emphasized the need for larger clinical trials to build on the results.

The study had no commercial funding. Marchetti disclosed having relationships with Arquer Diagnostics, AstraZeneca, Clovis Oncology, and other companies. Small disclosed having relationships with Janssen, Johnson & Johnson, and others. Teplinsky had no disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

Telephone outreach by a nurse practitioner (NP) providing counseling and care coordination reduced the gaps in breast and cervical cancer screenings among women veterans in rural areas, according to a retrospective study.

METHODOLOGY:

• Researchers conducted a retrospective chart review of 55 women veterans who received interventions related to breast or cervical cancer screening at a rural Veterans Health Administration health care system.
• A Boost team, including an NP, a medical director, a program coordinator, and a program evaluation team, was established to provide care coordination and counseling for these participants.
• The NP conducted outreach by telephone to these participants receiving care at five community-based outpatient clinics located in rural counties and helped coordinate access to screening appointments through the Office of Community Care.
• Outcomes included the number of veterans due for breast or cervical cancer screening at the time of outreach and the number of mammograms and Pap smears completed in the 12-month period following the intervention.

TAKEAWAY:

• Of the 55 veterans who received Boost interventions related to cancer screening, 35 (64%) were due for breast cancer screening and 27 (49%) were due for cervical cancer screening before the intervention.
• Following the Boost intervention, the number of veterans due for breast cancer and cervical cancer screenings decreased to 18 (32%) and 16 (29%), respectively.
• Among veterans due for breast cancer screening, 29 (83%) received counseling regarding screening and 17 (59%) of counseled participants completed mammography; however, among those due for cervical cancer screening, 22 (81%) received counseling and 11 (50%) completed screening.
• None of the veterans who were due for screening but did not receive counseling completed their screening, demonstrating the critical role of clinician-provided education and counseling.

IN PRACTICE:

“We hope to expand Boost outreach from one NP working part-time across two health systems to a national partnership of licensed independent providers conducting clinician-initiated outreach to a broader and geographically more diverse group of veterans,” the authors wrote.

SOURCE:

This study was led by Lina Vadlamani, MD, MBA, San Francisco Internal Medicine Residency Program, University of California, San Francisco. It was published online on April 24, 2026, in Military Medicine.

LIMITATIONS:

This study was a secondary analysis in which participants were not randomly assigned, limiting causal inferences. Veterans who answered the phone and engaged with the NP were likely easier to reach and potentially more proactive about their health than those who did not engage, and this selection bias may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded by the Department of Veterans Affairs, Veterans Health Administration, and Office of Rural Health. The authors reported having no relevant conflicts of interest.

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:

Telephone outreach by a nurse practitioner (NP) providing counseling and care coordination reduced the gaps in breast and cervical cancer screenings among women veterans in rural areas, according to a retrospective study.

METHODOLOGY:

• Researchers conducted a retrospective chart review of 55 women veterans who received interventions related to breast or cervical cancer screening at a rural Veterans Health Administration health care system.
• A Boost team, including an NP, a medical director, a program coordinator, and a program evaluation team, was established to provide care coordination and counseling for these participants.
• The NP conducted outreach by telephone to these participants receiving care at five community-based outpatient clinics located in rural counties and helped coordinate access to screening appointments through the Office of Community Care.
• Outcomes included the number of veterans due for breast or cervical cancer screening at the time of outreach and the number of mammograms and Pap smears completed in the 12-month period following the intervention.

TAKEAWAY:

• Of the 55 veterans who received Boost interventions related to cancer screening, 35 (64%) were due for breast cancer screening and 27 (49%) were due for cervical cancer screening before the intervention.
• Following the Boost intervention, the number of veterans due for breast cancer and cervical cancer screenings decreased to 18 (32%) and 16 (29%), respectively.
• Among veterans due for breast cancer screening, 29 (83%) received counseling regarding screening and 17 (59%) of counseled participants completed mammography; however, among those due for cervical cancer screening, 22 (81%) received counseling and 11 (50%) completed screening.
• None of the veterans who were due for screening but did not receive counseling completed their screening, demonstrating the critical role of clinician-provided education and counseling.

IN PRACTICE:

“We hope to expand Boost outreach from one NP working part-time across two health systems to a national partnership of licensed independent providers conducting clinician-initiated outreach to a broader and geographically more diverse group of veterans,” the authors wrote.

SOURCE:

This study was led by Lina Vadlamani, MD, MBA, San Francisco Internal Medicine Residency Program, University of California, San Francisco. It was published online on April 24, 2026, in Military Medicine.

LIMITATIONS:

This study was a secondary analysis in which participants were not randomly assigned, limiting causal inferences. Veterans who answered the phone and engaged with the NP were likely easier to reach and potentially more proactive about their health than those who did not engage, and this selection bias may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded by the Department of Veterans Affairs, Veterans Health Administration, and Office of Rural Health. The authors reported having no relevant conflicts of interest.

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:

Telephone outreach by a nurse practitioner (NP) providing counseling and care coordination reduced the gaps in breast and cervical cancer screenings among women veterans in rural areas, according to a retrospective study.

METHODOLOGY:

• Researchers conducted a retrospective chart review of 55 women veterans who received interventions related to breast or cervical cancer screening at a rural Veterans Health Administration health care system.
• A Boost team, including an NP, a medical director, a program coordinator, and a program evaluation team, was established to provide care coordination and counseling for these participants.
• The NP conducted outreach by telephone to these participants receiving care at five community-based outpatient clinics located in rural counties and helped coordinate access to screening appointments through the Office of Community Care.
• Outcomes included the number of veterans due for breast or cervical cancer screening at the time of outreach and the number of mammograms and Pap smears completed in the 12-month period following the intervention.

TAKEAWAY:

• Of the 55 veterans who received Boost interventions related to cancer screening, 35 (64%) were due for breast cancer screening and 27 (49%) were due for cervical cancer screening before the intervention.
• Following the Boost intervention, the number of veterans due for breast cancer and cervical cancer screenings decreased to 18 (32%) and 16 (29%), respectively.
• Among veterans due for breast cancer screening, 29 (83%) received counseling regarding screening and 17 (59%) of counseled participants completed mammography; however, among those due for cervical cancer screening, 22 (81%) received counseling and 11 (50%) completed screening.
• None of the veterans who were due for screening but did not receive counseling completed their screening, demonstrating the critical role of clinician-provided education and counseling.

IN PRACTICE:

“We hope to expand Boost outreach from one NP working part-time across two health systems to a national partnership of licensed independent providers conducting clinician-initiated outreach to a broader and geographically more diverse group of veterans,” the authors wrote.

SOURCE:

This study was led by Lina Vadlamani, MD, MBA, San Francisco Internal Medicine Residency Program, University of California, San Francisco. It was published online on April 24, 2026, in Military Medicine.

LIMITATIONS:

This study was a secondary analysis in which participants were not randomly assigned, limiting causal inferences. Veterans who answered the phone and engaged with the NP were likely easier to reach and potentially more proactive about their health than those who did not engage, and this selection bias may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded by the Department of Veterans Affairs, Veterans Health Administration, and Office of Rural Health. The authors reported having no relevant conflicts of interest.

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.