Federal Practitioner

Lower back pain (LBP) affects an estimated 9.4% of the global population and has resulted in more years lived with disability than any other health condition.¹ LBP affects a wide range of populations, but US veterans have been shown to have significantly higher rates of back pain than nonveterans. The National Institutes of Health reports that 65.6% of veterans experience chronic pain; 9.1% of veterans experience severe, chronic pain.² Chronic back pain is treated by a range of methods, including medications, surgery, physical therapy (PT), patient education, and behavioral therapy.³ However, chronic neuropathic back pain has been shown to have limited responsiveness to medication.⁴

Neuropathic pain is caused by lesions in the somatosensory nervous system, resulting in spontaneous pain and amplified pain responses to both painful and nonpainful stimuli.⁵ The most common location for neuropathic pain is the back and legs. Between 10% and 40% of people who undergo lumbosacral spine surgery to treat neuropathic radicular pain will experience further neuropathic pain.⁶ This condition is referred to as failed back surgery syndrome or postlaminectomy syndrome (PLS). While neuropathic back pain has had limited responsiveness to medication and repeated lumbosacral spine surgery, spinal cord stimulation (SCS) has shown promise as an effective form of pain treatment for those experiencing PLS and other spine disorders.^7-10 In addition, SCS therapy has had a very low incidence of complications, which may be on the decline with recent technological advancements.¹¹ Patients with a diagnosis of PLS, LBP, or complex regional pain syndrome (CRPS) who have not responded to medications, therapy, and/or injections for ≥ 6 months were eligible for a trial of SCS therapy. Trial leads were placed via the percutaneous route with the battery strapped to the waistline for 3 to 5 days and were removed in clinic. Patients who experienced > 60% pain relief and functional improvement received a SCS implant.

The effectiveness of SCS has been demonstrated in a nonveteran population, but it has not been studied in a veteran population.¹² US Department of Veterans Affairs (VA) health care coverage is different from Medicare and private insurance in that it is classified as a benefit and not insurance. The goals of treatment at the VA may include considerations in addition to feeling better, and patient presentations may not align with those in the private sector.

We hypothesize that SCS is both a safe and beneficial treatment option for veterans with chronic intractable spine and/or extremity pain. The purpose of this study was to determine the efficacy and safety of SCS in a veteran population.

Methods

The efficacy and safety of SCS was determined via a retrospective study. Inclusion criteria for the study consisted of any Southeastern Louisiana Veterans Health Care System (SLVHCS) patient who had an SCS trial and/or implant from 2008 to 2020. Eligible veterans must have had chronic pain for at least 6 months and had previously tried multiple medications, PT, transcutaneous nerve stimulation, facet injections, epidural steroid injections, or surgery without success. For medication therapy to be considered unsuccessful, it must have included acetaminophen, nonsteroidal anti-inflammatory drugs, and ≥ 1 adjuvant medication (gabapentin, duloxetine, amitriptyline, lidocaine, and menthol). A diagnosis of chronic LBP, PLS, cervical or lumbar spondylosis with radiculopathy, complex regional pain syndrome, or chronic pain syndrome was required for eligibility. Patients whose pain decreased by > 60% and had functional improvement in a 3- to 5-day trial received SCS implantation with percutaneous leads by a pain physician or paddle lead by a neurosurgeon.

The SLVHCS Institutional Review Board approved this study. Electronic health records were reviewed to determine patient age, anthropometric data, and date of SCS implantation. Patients were then called and interviewed to complete a survey. After obtaining verbal consent to the study, subjects were surveyed regarding whether the patient would recommend the procedure to peers, adverse effects (AEs) or complications, and the ability to decrease opiates if applicable. A verbal Pain Outcome Questionnaire (POQ) assessment of activities of daily living also was given during the phone interview regarding pain levels before SCS and at the time of the phone interview.¹³ (eAppendix available at doi:10.12788/fp.0204) Following the survey, a chart review was performed to corroborate the given AEs or complications and opiate use information. Before and after results of the POQ were compared via a paired sample t test, and P values < .05 were considered significant. Analyses were performed by IBM SPSS, version 26.

The primary outcome measure for this study was whether veterans would recommend SCS to their peers; in our view, this categorical outcome measure seemed to be more valuable to share with future patients who might be candidates for SCS. Since VA health care coverage and goals of treatment may be different from a nonveteran population, we opted to use this primary measure to decrease the possibility of confounding variables.

Secondary outcome measures included changes in POC scores, improvements in activities of daily living, and decreases in use of opioid pain medications.

POQ responses were recorded during the telephone interviews (0 to 10 scale). A paired sample t test was conducted to compare pain levels before and after SCS implant. Pain levels were gathered in the single phone call. Patient opioid usage, if applicable, was assessed by converting medications to morphine milligram equivalent dosing (MMED). Since patients who were on chronic opioids took multiple formulations, we changed the total daily dose to all morphine; for this study, morphine was considered equivalent to hydrocodone, and oxycodone was 1.5x morphine.

Results

Of the 90 SLVHCS patients who received an SCS implant between 2008 and 2020, 76 were reached by telephone and 65 had their responses recorded in the study. Of the 11 patients who were not included, 5 had the SCS removed; it is unclear whether these veterans would have recommended the treatment. Four were unable to quantify pain and/or SCS effects, and 2 were excluded due to a dementia diagnosis years after the implant. The mean (SD) age of participants was 63.9 (10.3) years. Forty percent of patients had a diabetes mellitus diagnosis and 1 had prediabetes. Patients’ most common qualifying diagnosis for SCS was PLS (47.7%) followed by chronic LBP (26.2%). A percutaneous 2-lead technique was the most common type of SCS type used (60.0%) followed by 1-lead (21.5%). The most common SCS manufacturer was Boston Scientific (87.7%)(Table 1). Most veterans (76.9%) recommended SCS to their peers; 13.8% did not recommend SCS; 9.2% were undecided and stated that they were unable to recommend because they did not want to persuade a peer to get SCS (Figure).

There was a statistically significant decrease in opioid use for the 40 veterans for whom pain medication was converted (P < .001)(Table 2). Six patients reported using opioids at some point but could not remember their dose, and no records were found in their chart review, so they were not included in the MMED analysis. In that group, 4 patients reported using opioids before SCS but discontinued the opioid use after SCS implantation, and 2 patients noted using opioids before SCS and concomitantly. Eighteen subjects reported no opioid use at any point before or after SCS (Table 3).

There were few life-threatening complications of SCS. Three veterans developed skin dehiscence; 2 had dehiscence at the battery/generator site, and 1 had dehiscence at the lead anchor site. Two patients with dehiscence also had morbid obesity, and the third had postoperative malnourishment. The dehiscence occurred 3 and 8 months postoperation. All 3 patients with dehiscence had the SCS explanted, though they were eager to get a new SCS implanted as soon as possible because SCS was their most successful treatment to date.

Discussion

In this nonrandomized retrospective review, SCS was shown to be an effective treatment for intractable spine and/or extremity pain. Veterans’ pain levels were significantly reduced following SCS implantation, and more than three-fourths of veterans recommended SCS to their peers. We used the recommendation of SCS to peers as the most important metric regarding the effectiveness of SCS, as this measure was felt to be more valuable to share with future patients; furthermore, categorical analysis has been shown to be more valuable than ordinal pain scales to measure pain.¹⁴ In addition to wanting to expand the available research to the general public, we wanted a measure that we could easily relay to our patient population regarding SCS.

The explant rate of 14.5% among surveyed veterans falls at the higher end of the normal ranges found in previous studies of long-term SCS outcomes.^15-17 One possible reason for the higher rate is that we did not differentiate based on the reason for the explant (ie, no benefit, further surgery needed for underlying medical condition, or SCS-specific complications). Another possible contributing factor to the higher than expected explant rate is the geographic location in the New Orleans metro area; New Orleans is considered to have one of the highest rates of obesity in the United States and obesity typically has other diseases associated with it such as hypertension and diabetes mellitus.

Limitations

Limitations of the study include the relatively low number of subjects, subjective nature of the interview questions, and the patients’ answers. Typically the POQ has been used as a prospective assessment of pain; whether it is valid in a retrospective analysis is not clear. While there was a statistically significant decrease of opioid use after getting SCS, this study can only show correlation, not causation. During the study period, there has been a drastic change in opioid prescribing patterns and efforts to decrease the amount of opioids prescribed.

Subjects also were asked to rate their pain and quality of life before SCS. Some subjects had SCS implantation up to 10 years prior to the phone interview. The variable amount of time between SCS implantation and interview likely affected subjects’ responses. Chronic pain is a moving target. Patients have good days and bad days that would likely change opinions on SCS benefits on a single phone interview. Some patients needed battery replacements at the time of the interview (battery life averaged about 3 to 5 years in our study population) and were asked to report current levels of pain from the perspective of when their batteries were still functional, further affecting results.

Conclusions

SCS was shown to improve the quality of life of US veterans at SLVHCS across a wide variety of metrics, including activities of daily living, as well as mental and physical health. For veterans with chronic intractable pain who have tried and failed more conservative treatments, SCS is a great treatment.

Lower back pain (LBP) affects an estimated 9.4% of the global population and has resulted in more years lived with disability than any other health condition.¹ LBP affects a wide range of populations, but US veterans have been shown to have significantly higher rates of back pain than nonveterans. The National Institutes of Health reports that 65.6% of veterans experience chronic pain; 9.1% of veterans experience severe, chronic pain.² Chronic back pain is treated by a range of methods, including medications, surgery, physical therapy (PT), patient education, and behavioral therapy.³ However, chronic neuropathic back pain has been shown to have limited responsiveness to medication.⁴

Neuropathic pain is caused by lesions in the somatosensory nervous system, resulting in spontaneous pain and amplified pain responses to both painful and nonpainful stimuli.⁵ The most common location for neuropathic pain is the back and legs. Between 10% and 40% of people who undergo lumbosacral spine surgery to treat neuropathic radicular pain will experience further neuropathic pain.⁶ This condition is referred to as failed back surgery syndrome or postlaminectomy syndrome (PLS). While neuropathic back pain has had limited responsiveness to medication and repeated lumbosacral spine surgery, spinal cord stimulation (SCS) has shown promise as an effective form of pain treatment for those experiencing PLS and other spine disorders.^7-10 In addition, SCS therapy has had a very low incidence of complications, which may be on the decline with recent technological advancements.¹¹ Patients with a diagnosis of PLS, LBP, or complex regional pain syndrome (CRPS) who have not responded to medications, therapy, and/or injections for ≥ 6 months were eligible for a trial of SCS therapy. Trial leads were placed via the percutaneous route with the battery strapped to the waistline for 3 to 5 days and were removed in clinic. Patients who experienced > 60% pain relief and functional improvement received a SCS implant.

The effectiveness of SCS has been demonstrated in a nonveteran population, but it has not been studied in a veteran population.¹² US Department of Veterans Affairs (VA) health care coverage is different from Medicare and private insurance in that it is classified as a benefit and not insurance. The goals of treatment at the VA may include considerations in addition to feeling better, and patient presentations may not align with those in the private sector.

We hypothesize that SCS is both a safe and beneficial treatment option for veterans with chronic intractable spine and/or extremity pain. The purpose of this study was to determine the efficacy and safety of SCS in a veteran population.

Methods

The efficacy and safety of SCS was determined via a retrospective study. Inclusion criteria for the study consisted of any Southeastern Louisiana Veterans Health Care System (SLVHCS) patient who had an SCS trial and/or implant from 2008 to 2020. Eligible veterans must have had chronic pain for at least 6 months and had previously tried multiple medications, PT, transcutaneous nerve stimulation, facet injections, epidural steroid injections, or surgery without success. For medication therapy to be considered unsuccessful, it must have included acetaminophen, nonsteroidal anti-inflammatory drugs, and ≥ 1 adjuvant medication (gabapentin, duloxetine, amitriptyline, lidocaine, and menthol). A diagnosis of chronic LBP, PLS, cervical or lumbar spondylosis with radiculopathy, complex regional pain syndrome, or chronic pain syndrome was required for eligibility. Patients whose pain decreased by > 60% and had functional improvement in a 3- to 5-day trial received SCS implantation with percutaneous leads by a pain physician or paddle lead by a neurosurgeon.

The SLVHCS Institutional Review Board approved this study. Electronic health records were reviewed to determine patient age, anthropometric data, and date of SCS implantation. Patients were then called and interviewed to complete a survey. After obtaining verbal consent to the study, subjects were surveyed regarding whether the patient would recommend the procedure to peers, adverse effects (AEs) or complications, and the ability to decrease opiates if applicable. A verbal Pain Outcome Questionnaire (POQ) assessment of activities of daily living also was given during the phone interview regarding pain levels before SCS and at the time of the phone interview.¹³ (eAppendix available at doi:10.12788/fp.0204) Following the survey, a chart review was performed to corroborate the given AEs or complications and opiate use information. Before and after results of the POQ were compared via a paired sample t test, and P values < .05 were considered significant. Analyses were performed by IBM SPSS, version 26.

The primary outcome measure for this study was whether veterans would recommend SCS to their peers; in our view, this categorical outcome measure seemed to be more valuable to share with future patients who might be candidates for SCS. Since VA health care coverage and goals of treatment may be different from a nonveteran population, we opted to use this primary measure to decrease the possibility of confounding variables.

Secondary outcome measures included changes in POC scores, improvements in activities of daily living, and decreases in use of opioid pain medications.

POQ responses were recorded during the telephone interviews (0 to 10 scale). A paired sample t test was conducted to compare pain levels before and after SCS implant. Pain levels were gathered in the single phone call. Patient opioid usage, if applicable, was assessed by converting medications to morphine milligram equivalent dosing (MMED). Since patients who were on chronic opioids took multiple formulations, we changed the total daily dose to all morphine; for this study, morphine was considered equivalent to hydrocodone, and oxycodone was 1.5x morphine.

Results

Of the 90 SLVHCS patients who received an SCS implant between 2008 and 2020, 76 were reached by telephone and 65 had their responses recorded in the study. Of the 11 patients who were not included, 5 had the SCS removed; it is unclear whether these veterans would have recommended the treatment. Four were unable to quantify pain and/or SCS effects, and 2 were excluded due to a dementia diagnosis years after the implant. The mean (SD) age of participants was 63.9 (10.3) years. Forty percent of patients had a diabetes mellitus diagnosis and 1 had prediabetes. Patients’ most common qualifying diagnosis for SCS was PLS (47.7%) followed by chronic LBP (26.2%). A percutaneous 2-lead technique was the most common type of SCS type used (60.0%) followed by 1-lead (21.5%). The most common SCS manufacturer was Boston Scientific (87.7%)(Table 1). Most veterans (76.9%) recommended SCS to their peers; 13.8% did not recommend SCS; 9.2% were undecided and stated that they were unable to recommend because they did not want to persuade a peer to get SCS (Figure).

There was a statistically significant decrease in opioid use for the 40 veterans for whom pain medication was converted (P < .001)(Table 2). Six patients reported using opioids at some point but could not remember their dose, and no records were found in their chart review, so they were not included in the MMED analysis. In that group, 4 patients reported using opioids before SCS but discontinued the opioid use after SCS implantation, and 2 patients noted using opioids before SCS and concomitantly. Eighteen subjects reported no opioid use at any point before or after SCS (Table 3).

There were few life-threatening complications of SCS. Three veterans developed skin dehiscence; 2 had dehiscence at the battery/generator site, and 1 had dehiscence at the lead anchor site. Two patients with dehiscence also had morbid obesity, and the third had postoperative malnourishment. The dehiscence occurred 3 and 8 months postoperation. All 3 patients with dehiscence had the SCS explanted, though they were eager to get a new SCS implanted as soon as possible because SCS was their most successful treatment to date.

Discussion

In this nonrandomized retrospective review, SCS was shown to be an effective treatment for intractable spine and/or extremity pain. Veterans’ pain levels were significantly reduced following SCS implantation, and more than three-fourths of veterans recommended SCS to their peers. We used the recommendation of SCS to peers as the most important metric regarding the effectiveness of SCS, as this measure was felt to be more valuable to share with future patients; furthermore, categorical analysis has been shown to be more valuable than ordinal pain scales to measure pain.¹⁴ In addition to wanting to expand the available research to the general public, we wanted a measure that we could easily relay to our patient population regarding SCS.

The explant rate of 14.5% among surveyed veterans falls at the higher end of the normal ranges found in previous studies of long-term SCS outcomes.^15-17 One possible reason for the higher rate is that we did not differentiate based on the reason for the explant (ie, no benefit, further surgery needed for underlying medical condition, or SCS-specific complications). Another possible contributing factor to the higher than expected explant rate is the geographic location in the New Orleans metro area; New Orleans is considered to have one of the highest rates of obesity in the United States and obesity typically has other diseases associated with it such as hypertension and diabetes mellitus.

Limitations

Limitations of the study include the relatively low number of subjects, subjective nature of the interview questions, and the patients’ answers. Typically the POQ has been used as a prospective assessment of pain; whether it is valid in a retrospective analysis is not clear. While there was a statistically significant decrease of opioid use after getting SCS, this study can only show correlation, not causation. During the study period, there has been a drastic change in opioid prescribing patterns and efforts to decrease the amount of opioids prescribed.

Subjects also were asked to rate their pain and quality of life before SCS. Some subjects had SCS implantation up to 10 years prior to the phone interview. The variable amount of time between SCS implantation and interview likely affected subjects’ responses. Chronic pain is a moving target. Patients have good days and bad days that would likely change opinions on SCS benefits on a single phone interview. Some patients needed battery replacements at the time of the interview (battery life averaged about 3 to 5 years in our study population) and were asked to report current levels of pain from the perspective of when their batteries were still functional, further affecting results.

Conclusions

SCS was shown to improve the quality of life of US veterans at SLVHCS across a wide variety of metrics, including activities of daily living, as well as mental and physical health. For veterans with chronic intractable pain who have tried and failed more conservative treatments, SCS is a great treatment.

Lower back pain (LBP) affects an estimated 9.4% of the global population and has resulted in more years lived with disability than any other health condition.¹ LBP affects a wide range of populations, but US veterans have been shown to have significantly higher rates of back pain than nonveterans. The National Institutes of Health reports that 65.6% of veterans experience chronic pain; 9.1% of veterans experience severe, chronic pain.² Chronic back pain is treated by a range of methods, including medications, surgery, physical therapy (PT), patient education, and behavioral therapy.³ However, chronic neuropathic back pain has been shown to have limited responsiveness to medication.⁴

Neuropathic pain is caused by lesions in the somatosensory nervous system, resulting in spontaneous pain and amplified pain responses to both painful and nonpainful stimuli.⁵ The most common location for neuropathic pain is the back and legs. Between 10% and 40% of people who undergo lumbosacral spine surgery to treat neuropathic radicular pain will experience further neuropathic pain.⁶ This condition is referred to as failed back surgery syndrome or postlaminectomy syndrome (PLS). While neuropathic back pain has had limited responsiveness to medication and repeated lumbosacral spine surgery, spinal cord stimulation (SCS) has shown promise as an effective form of pain treatment for those experiencing PLS and other spine disorders.^7-10 In addition, SCS therapy has had a very low incidence of complications, which may be on the decline with recent technological advancements.¹¹ Patients with a diagnosis of PLS, LBP, or complex regional pain syndrome (CRPS) who have not responded to medications, therapy, and/or injections for ≥ 6 months were eligible for a trial of SCS therapy. Trial leads were placed via the percutaneous route with the battery strapped to the waistline for 3 to 5 days and were removed in clinic. Patients who experienced > 60% pain relief and functional improvement received a SCS implant.

The effectiveness of SCS has been demonstrated in a nonveteran population, but it has not been studied in a veteran population.¹² US Department of Veterans Affairs (VA) health care coverage is different from Medicare and private insurance in that it is classified as a benefit and not insurance. The goals of treatment at the VA may include considerations in addition to feeling better, and patient presentations may not align with those in the private sector.

We hypothesize that SCS is both a safe and beneficial treatment option for veterans with chronic intractable spine and/or extremity pain. The purpose of this study was to determine the efficacy and safety of SCS in a veteran population.

Methods

The efficacy and safety of SCS was determined via a retrospective study. Inclusion criteria for the study consisted of any Southeastern Louisiana Veterans Health Care System (SLVHCS) patient who had an SCS trial and/or implant from 2008 to 2020. Eligible veterans must have had chronic pain for at least 6 months and had previously tried multiple medications, PT, transcutaneous nerve stimulation, facet injections, epidural steroid injections, or surgery without success. For medication therapy to be considered unsuccessful, it must have included acetaminophen, nonsteroidal anti-inflammatory drugs, and ≥ 1 adjuvant medication (gabapentin, duloxetine, amitriptyline, lidocaine, and menthol). A diagnosis of chronic LBP, PLS, cervical or lumbar spondylosis with radiculopathy, complex regional pain syndrome, or chronic pain syndrome was required for eligibility. Patients whose pain decreased by > 60% and had functional improvement in a 3- to 5-day trial received SCS implantation with percutaneous leads by a pain physician or paddle lead by a neurosurgeon.

The SLVHCS Institutional Review Board approved this study. Electronic health records were reviewed to determine patient age, anthropometric data, and date of SCS implantation. Patients were then called and interviewed to complete a survey. After obtaining verbal consent to the study, subjects were surveyed regarding whether the patient would recommend the procedure to peers, adverse effects (AEs) or complications, and the ability to decrease opiates if applicable. A verbal Pain Outcome Questionnaire (POQ) assessment of activities of daily living also was given during the phone interview regarding pain levels before SCS and at the time of the phone interview.¹³ (eAppendix available at doi:10.12788/fp.0204) Following the survey, a chart review was performed to corroborate the given AEs or complications and opiate use information. Before and after results of the POQ were compared via a paired sample t test, and P values < .05 were considered significant. Analyses were performed by IBM SPSS, version 26.

The primary outcome measure for this study was whether veterans would recommend SCS to their peers; in our view, this categorical outcome measure seemed to be more valuable to share with future patients who might be candidates for SCS. Since VA health care coverage and goals of treatment may be different from a nonveteran population, we opted to use this primary measure to decrease the possibility of confounding variables.

Secondary outcome measures included changes in POC scores, improvements in activities of daily living, and decreases in use of opioid pain medications.

POQ responses were recorded during the telephone interviews (0 to 10 scale). A paired sample t test was conducted to compare pain levels before and after SCS implant. Pain levels were gathered in the single phone call. Patient opioid usage, if applicable, was assessed by converting medications to morphine milligram equivalent dosing (MMED). Since patients who were on chronic opioids took multiple formulations, we changed the total daily dose to all morphine; for this study, morphine was considered equivalent to hydrocodone, and oxycodone was 1.5x morphine.

Results

Of the 90 SLVHCS patients who received an SCS implant between 2008 and 2020, 76 were reached by telephone and 65 had their responses recorded in the study. Of the 11 patients who were not included, 5 had the SCS removed; it is unclear whether these veterans would have recommended the treatment. Four were unable to quantify pain and/or SCS effects, and 2 were excluded due to a dementia diagnosis years after the implant. The mean (SD) age of participants was 63.9 (10.3) years. Forty percent of patients had a diabetes mellitus diagnosis and 1 had prediabetes. Patients’ most common qualifying diagnosis for SCS was PLS (47.7%) followed by chronic LBP (26.2%). A percutaneous 2-lead technique was the most common type of SCS type used (60.0%) followed by 1-lead (21.5%). The most common SCS manufacturer was Boston Scientific (87.7%)(Table 1). Most veterans (76.9%) recommended SCS to their peers; 13.8% did not recommend SCS; 9.2% were undecided and stated that they were unable to recommend because they did not want to persuade a peer to get SCS (Figure).

There was a statistically significant decrease in opioid use for the 40 veterans for whom pain medication was converted (P < .001)(Table 2). Six patients reported using opioids at some point but could not remember their dose, and no records were found in their chart review, so they were not included in the MMED analysis. In that group, 4 patients reported using opioids before SCS but discontinued the opioid use after SCS implantation, and 2 patients noted using opioids before SCS and concomitantly. Eighteen subjects reported no opioid use at any point before or after SCS (Table 3).

There were few life-threatening complications of SCS. Three veterans developed skin dehiscence; 2 had dehiscence at the battery/generator site, and 1 had dehiscence at the lead anchor site. Two patients with dehiscence also had morbid obesity, and the third had postoperative malnourishment. The dehiscence occurred 3 and 8 months postoperation. All 3 patients with dehiscence had the SCS explanted, though they were eager to get a new SCS implanted as soon as possible because SCS was their most successful treatment to date.

Discussion

In this nonrandomized retrospective review, SCS was shown to be an effective treatment for intractable spine and/or extremity pain. Veterans’ pain levels were significantly reduced following SCS implantation, and more than three-fourths of veterans recommended SCS to their peers. We used the recommendation of SCS to peers as the most important metric regarding the effectiveness of SCS, as this measure was felt to be more valuable to share with future patients; furthermore, categorical analysis has been shown to be more valuable than ordinal pain scales to measure pain.¹⁴ In addition to wanting to expand the available research to the general public, we wanted a measure that we could easily relay to our patient population regarding SCS.

The explant rate of 14.5% among surveyed veterans falls at the higher end of the normal ranges found in previous studies of long-term SCS outcomes.^15-17 One possible reason for the higher rate is that we did not differentiate based on the reason for the explant (ie, no benefit, further surgery needed for underlying medical condition, or SCS-specific complications). Another possible contributing factor to the higher than expected explant rate is the geographic location in the New Orleans metro area; New Orleans is considered to have one of the highest rates of obesity in the United States and obesity typically has other diseases associated with it such as hypertension and diabetes mellitus.

Limitations

Limitations of the study include the relatively low number of subjects, subjective nature of the interview questions, and the patients’ answers. Typically the POQ has been used as a prospective assessment of pain; whether it is valid in a retrospective analysis is not clear. While there was a statistically significant decrease of opioid use after getting SCS, this study can only show correlation, not causation. During the study period, there has been a drastic change in opioid prescribing patterns and efforts to decrease the amount of opioids prescribed.

Subjects also were asked to rate their pain and quality of life before SCS. Some subjects had SCS implantation up to 10 years prior to the phone interview. The variable amount of time between SCS implantation and interview likely affected subjects’ responses. Chronic pain is a moving target. Patients have good days and bad days that would likely change opinions on SCS benefits on a single phone interview. Some patients needed battery replacements at the time of the interview (battery life averaged about 3 to 5 years in our study population) and were asked to report current levels of pain from the perspective of when their batteries were still functional, further affecting results.

Conclusions

SCS was shown to improve the quality of life of US veterans at SLVHCS across a wide variety of metrics, including activities of daily living, as well as mental and physical health. For veterans with chronic intractable pain who have tried and failed more conservative treatments, SCS is a great treatment.

The use of a rotating hinge distal femur replacement (DFR) for significant bone and soft tissue defects in the setting of total knee arthroplasty (TKA) revision has become increasingly more common. Although significant advancements have been made in modern DFR components, complications and failure rates remain high. The unanticipated early failure presented serves as the first reported case in the literature to our knowledge of a 180° rotation of a press-fit DFR.

Originally, DFRs were used primarily for oncology patients with substantial bone loss following large mass excisions. The utility of DFRs has grown to include massive bone loss in the setting of TKA revision, periprosthetic fractures, and periprosthetic joint infections.^1-3 DFRs help restore the joint line in the setting of significant bone loss and contain a rotating hinge mechanism that provides functional movement despite the loss of soft tissue constraints around the knee.^1-3

DFRs have been associated with early postoperative mobilization and decreased need for ambulatory devices at 1 year in revision TKA and periprosthetic and geriatric distal femur fractures.^4-6 Advances in prosthetic design, biomechanics, and fixation technique have led to improved survival rates.³ Despite these improvements, the overall complication rate remains high at 30 to 40%.^3-7 Commonly reported complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^3,4,7 Recent case studies also have reported on dislocation or disengagement of the rotating hinge.^8-11

In this case report, we present a patient who had a DFR as the second stage of a 2-stage TKA revision due to a periprosthetic joint infection with a postoperative complication of 180° rotation of the press-fit femoral component. Although this is a rare event, knowledge of this possible complication is important for arthroplasty surgeons.

Case Presentation

A patient with a history of hypertension, osteopenia, and rheumatoid arthritis underwent a primary right TKA in 2007. Ten weeks postoperatively, the patient had a ground-level fall that resulted in a right periprosthetic supracondylar distal femur fracture that was treated with a distal femur locking plate. The patient healed, however, with a significant golf club deformity (Figure 1). The patient did well for more than a decade but in 2019 was admitted with pelvic inflammatory disease and adnexal abscess that was treated with broad-spectrum IV antibiotics. Shortly after this admission, the patient developed a right knee periprosthetic infection with cultures positive for Ureaplasma parvum.

The patient then underwent a 2-stage revision of the infected TKA. Stage 1 consisted of explant of the TKA components as well as removal of the distal femur plate and screws and placement of an articulating antibiotic cement spacer (Figure 2). The patient completed 6 weeks of IV antibiotics. Following completion of the antibiotic course, we obtained a serum erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count, which were all within normal limits. A knee aspiration was performed and did not show signs of residual infection. Frozen histopathology was sent during the second stage of the revision and did not show infection. After the results of the frozen histopathology returned, the antibiotic spacer was removed, and the femoral canal was thoroughly debrided. Cement and fibrous tissue in the femoral canal were carefully removed. In the setting of significant bone loss and soft tissue compromise due to the previous infection and distal femur fracture, the Zimmer Biomet Orthopedic Salvage System (OSS) with porous coated press-fit elliptical femoral stem was utilized.

The femoral canal was reamed until good cortical chatter was obtained at 16 mm. Per the Biomet OSS guide, “For bowed (curved) long and short press-fit stems, the final flexible reamer shaft diameter may need to be larger than the definitive trial and implant diameter.” After trialing, size 15.5 mm was selected for implantation. Intraoperatively the final stem was noted to have good interference fit after insertion and was stable throughout knee range of motion and varus/valgus stress testing. The patient did well with mobilization while in the hospital postoperatively and was discharged home (Figure 3).

Five days after discharge, the patient kicked the repaired knee onto a chair for rest and elevation and experienced extreme pain and was unable to flex the knee. On presentation to the emergency department, the X-rays showed 180° rotation around the longitudinal axis of the femoral component without any other obvious component failure or fracture (Figure 4). The patient was taken back to surgery the following day. Intraoperatively, the femoral stem was found to be loose and rotated 180° (Figure 5). No failure or dislocation of the tibial or rotating hinge components were identified. The press-fit femoral stem was removed and replaced with a cemented stem (Figure 6).

Discussion

Despite advancements in DFRs and increasing use in the setting of revision TKA, the procedure remains high risk with respect to postoperative complications.^3-7 Vertesich and colleagues demonstrated that 43.3% of patients who underwent DFR for failed TKA developed at least 1 postoperative complication that required a return to the operating room.⁷Physicians need to be aware of the high rate of complications and counsel patients appropriately preoperatively.

Complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^4,7 Soft tissue failures include insufficiency or rupture of the extensor mechanism and patella dislocation.^4,7 Structural failures include fracture of the hinge mechanism, dissociation of the component from the stem, rotating hinge-bushing failure, and dislocation of the hinge.^4,7 In the acute postoperative period, the most common complications are infection and rotating-hinge dislocation/failure.^3,12 There are various component options available for DFRs, including straight vs curved, cemented vs cementless/press-fit, and long vs short stems.¹³ Studies have sought to elucidate the ideal implant to decrease the rate of complications. Lu and colleagues demonstrated that curved press-fit short stems provided a stable interface without loosening over the short term (2 years) in 42 patients.¹³ No implant failures or incidences of aseptic loosening occurred in their study.¹³

The implant used in this case was a curved press-fit short-stem DFR. It was thought that this patient was young and with good enough bone quality that a press-fit short stem would be best in preserving bone stock. Both the technique guide and literature support reaming 0 to 2 mm greater than the planned stem size to accommodate the implant curvature.¹³ In this case, the intramedullary canal was reamed 0.5 mm larger than the curved stem that was implanted (16 mm and 15.5 mm, respectively). Intraoperatively during the index DFR, the component was stable and seemed to have a good press-fit interface. Despite this, obvious loosening of the component occurred with a relatively low-energy mechanism when the patient kicked the leg onto a chair, causing just enough force and femoral rotation to result in 180° rotation of the component.

Conclusions

We present this case report to make surgeons aware of this rare but serious complication. Although the final implant is a porous and curved stem, careful attention should be made during trialing to use the best-fitting implant to prevent this complication. If an adequate interference fit cannot be obtained, cementing the component may be required to prevent its loosening and catastrophic failure.

The use of a rotating hinge distal femur replacement (DFR) for significant bone and soft tissue defects in the setting of total knee arthroplasty (TKA) revision has become increasingly more common. Although significant advancements have been made in modern DFR components, complications and failure rates remain high. The unanticipated early failure presented serves as the first reported case in the literature to our knowledge of a 180° rotation of a press-fit DFR.

Originally, DFRs were used primarily for oncology patients with substantial bone loss following large mass excisions. The utility of DFRs has grown to include massive bone loss in the setting of TKA revision, periprosthetic fractures, and periprosthetic joint infections.^1-3 DFRs help restore the joint line in the setting of significant bone loss and contain a rotating hinge mechanism that provides functional movement despite the loss of soft tissue constraints around the knee.^1-3

DFRs have been associated with early postoperative mobilization and decreased need for ambulatory devices at 1 year in revision TKA and periprosthetic and geriatric distal femur fractures.^4-6 Advances in prosthetic design, biomechanics, and fixation technique have led to improved survival rates.³ Despite these improvements, the overall complication rate remains high at 30 to 40%.^3-7 Commonly reported complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^3,4,7 Recent case studies also have reported on dislocation or disengagement of the rotating hinge.^8-11

In this case report, we present a patient who had a DFR as the second stage of a 2-stage TKA revision due to a periprosthetic joint infection with a postoperative complication of 180° rotation of the press-fit femoral component. Although this is a rare event, knowledge of this possible complication is important for arthroplasty surgeons.

Case Presentation

A patient with a history of hypertension, osteopenia, and rheumatoid arthritis underwent a primary right TKA in 2007. Ten weeks postoperatively, the patient had a ground-level fall that resulted in a right periprosthetic supracondylar distal femur fracture that was treated with a distal femur locking plate. The patient healed, however, with a significant golf club deformity (Figure 1). The patient did well for more than a decade but in 2019 was admitted with pelvic inflammatory disease and adnexal abscess that was treated with broad-spectrum IV antibiotics. Shortly after this admission, the patient developed a right knee periprosthetic infection with cultures positive for Ureaplasma parvum.

The patient then underwent a 2-stage revision of the infected TKA. Stage 1 consisted of explant of the TKA components as well as removal of the distal femur plate and screws and placement of an articulating antibiotic cement spacer (Figure 2). The patient completed 6 weeks of IV antibiotics. Following completion of the antibiotic course, we obtained a serum erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count, which were all within normal limits. A knee aspiration was performed and did not show signs of residual infection. Frozen histopathology was sent during the second stage of the revision and did not show infection. After the results of the frozen histopathology returned, the antibiotic spacer was removed, and the femoral canal was thoroughly debrided. Cement and fibrous tissue in the femoral canal were carefully removed. In the setting of significant bone loss and soft tissue compromise due to the previous infection and distal femur fracture, the Zimmer Biomet Orthopedic Salvage System (OSS) with porous coated press-fit elliptical femoral stem was utilized.

The femoral canal was reamed until good cortical chatter was obtained at 16 mm. Per the Biomet OSS guide, “For bowed (curved) long and short press-fit stems, the final flexible reamer shaft diameter may need to be larger than the definitive trial and implant diameter.” After trialing, size 15.5 mm was selected for implantation. Intraoperatively the final stem was noted to have good interference fit after insertion and was stable throughout knee range of motion and varus/valgus stress testing. The patient did well with mobilization while in the hospital postoperatively and was discharged home (Figure 3).

Five days after discharge, the patient kicked the repaired knee onto a chair for rest and elevation and experienced extreme pain and was unable to flex the knee. On presentation to the emergency department, the X-rays showed 180° rotation around the longitudinal axis of the femoral component without any other obvious component failure or fracture (Figure 4). The patient was taken back to surgery the following day. Intraoperatively, the femoral stem was found to be loose and rotated 180° (Figure 5). No failure or dislocation of the tibial or rotating hinge components were identified. The press-fit femoral stem was removed and replaced with a cemented stem (Figure 6).

Discussion

Despite advancements in DFRs and increasing use in the setting of revision TKA, the procedure remains high risk with respect to postoperative complications.^3-7 Vertesich and colleagues demonstrated that 43.3% of patients who underwent DFR for failed TKA developed at least 1 postoperative complication that required a return to the operating room.⁷Physicians need to be aware of the high rate of complications and counsel patients appropriately preoperatively.

Complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^4,7 Soft tissue failures include insufficiency or rupture of the extensor mechanism and patella dislocation.^4,7 Structural failures include fracture of the hinge mechanism, dissociation of the component from the stem, rotating hinge-bushing failure, and dislocation of the hinge.^4,7 In the acute postoperative period, the most common complications are infection and rotating-hinge dislocation/failure.^3,12 There are various component options available for DFRs, including straight vs curved, cemented vs cementless/press-fit, and long vs short stems.¹³ Studies have sought to elucidate the ideal implant to decrease the rate of complications. Lu and colleagues demonstrated that curved press-fit short stems provided a stable interface without loosening over the short term (2 years) in 42 patients.¹³ No implant failures or incidences of aseptic loosening occurred in their study.¹³

The implant used in this case was a curved press-fit short-stem DFR. It was thought that this patient was young and with good enough bone quality that a press-fit short stem would be best in preserving bone stock. Both the technique guide and literature support reaming 0 to 2 mm greater than the planned stem size to accommodate the implant curvature.¹³ In this case, the intramedullary canal was reamed 0.5 mm larger than the curved stem that was implanted (16 mm and 15.5 mm, respectively). Intraoperatively during the index DFR, the component was stable and seemed to have a good press-fit interface. Despite this, obvious loosening of the component occurred with a relatively low-energy mechanism when the patient kicked the leg onto a chair, causing just enough force and femoral rotation to result in 180° rotation of the component.

Conclusions

We present this case report to make surgeons aware of this rare but serious complication. Although the final implant is a porous and curved stem, careful attention should be made during trialing to use the best-fitting implant to prevent this complication. If an adequate interference fit cannot be obtained, cementing the component may be required to prevent its loosening and catastrophic failure.

The use of a rotating hinge distal femur replacement (DFR) for significant bone and soft tissue defects in the setting of total knee arthroplasty (TKA) revision has become increasingly more common. Although significant advancements have been made in modern DFR components, complications and failure rates remain high. The unanticipated early failure presented serves as the first reported case in the literature to our knowledge of a 180° rotation of a press-fit DFR.

Originally, DFRs were used primarily for oncology patients with substantial bone loss following large mass excisions. The utility of DFRs has grown to include massive bone loss in the setting of TKA revision, periprosthetic fractures, and periprosthetic joint infections.^1-3 DFRs help restore the joint line in the setting of significant bone loss and contain a rotating hinge mechanism that provides functional movement despite the loss of soft tissue constraints around the knee.^1-3

DFRs have been associated with early postoperative mobilization and decreased need for ambulatory devices at 1 year in revision TKA and periprosthetic and geriatric distal femur fractures.^4-6 Advances in prosthetic design, biomechanics, and fixation technique have led to improved survival rates.³ Despite these improvements, the overall complication rate remains high at 30 to 40%.^3-7 Commonly reported complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^3,4,7 Recent case studies also have reported on dislocation or disengagement of the rotating hinge.^8-11

In this case report, we present a patient who had a DFR as the second stage of a 2-stage TKA revision due to a periprosthetic joint infection with a postoperative complication of 180° rotation of the press-fit femoral component. Although this is a rare event, knowledge of this possible complication is important for arthroplasty surgeons.

Case Presentation

A patient with a history of hypertension, osteopenia, and rheumatoid arthritis underwent a primary right TKA in 2007. Ten weeks postoperatively, the patient had a ground-level fall that resulted in a right periprosthetic supracondylar distal femur fracture that was treated with a distal femur locking plate. The patient healed, however, with a significant golf club deformity (Figure 1). The patient did well for more than a decade but in 2019 was admitted with pelvic inflammatory disease and adnexal abscess that was treated with broad-spectrum IV antibiotics. Shortly after this admission, the patient developed a right knee periprosthetic infection with cultures positive for Ureaplasma parvum.

The patient then underwent a 2-stage revision of the infected TKA. Stage 1 consisted of explant of the TKA components as well as removal of the distal femur plate and screws and placement of an articulating antibiotic cement spacer (Figure 2). The patient completed 6 weeks of IV antibiotics. Following completion of the antibiotic course, we obtained a serum erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count, which were all within normal limits. A knee aspiration was performed and did not show signs of residual infection. Frozen histopathology was sent during the second stage of the revision and did not show infection. After the results of the frozen histopathology returned, the antibiotic spacer was removed, and the femoral canal was thoroughly debrided. Cement and fibrous tissue in the femoral canal were carefully removed. In the setting of significant bone loss and soft tissue compromise due to the previous infection and distal femur fracture, the Zimmer Biomet Orthopedic Salvage System (OSS) with porous coated press-fit elliptical femoral stem was utilized.

The femoral canal was reamed until good cortical chatter was obtained at 16 mm. Per the Biomet OSS guide, “For bowed (curved) long and short press-fit stems, the final flexible reamer shaft diameter may need to be larger than the definitive trial and implant diameter.” After trialing, size 15.5 mm was selected for implantation. Intraoperatively the final stem was noted to have good interference fit after insertion and was stable throughout knee range of motion and varus/valgus stress testing. The patient did well with mobilization while in the hospital postoperatively and was discharged home (Figure 3).

Five days after discharge, the patient kicked the repaired knee onto a chair for rest and elevation and experienced extreme pain and was unable to flex the knee. On presentation to the emergency department, the X-rays showed 180° rotation around the longitudinal axis of the femoral component without any other obvious component failure or fracture (Figure 4). The patient was taken back to surgery the following day. Intraoperatively, the femoral stem was found to be loose and rotated 180° (Figure 5). No failure or dislocation of the tibial or rotating hinge components were identified. The press-fit femoral stem was removed and replaced with a cemented stem (Figure 6).

Discussion

Despite advancements in DFRs and increasing use in the setting of revision TKA, the procedure remains high risk with respect to postoperative complications.^3-7 Vertesich and colleagues demonstrated that 43.3% of patients who underwent DFR for failed TKA developed at least 1 postoperative complication that required a return to the operating room.⁷Physicians need to be aware of the high rate of complications and counsel patients appropriately preoperatively.

Complications after DFR include infection, aseptic loosening, soft tissue failure, and structural failure.^4,7 Soft tissue failures include insufficiency or rupture of the extensor mechanism and patella dislocation.^4,7 Structural failures include fracture of the hinge mechanism, dissociation of the component from the stem, rotating hinge-bushing failure, and dislocation of the hinge.^4,7 In the acute postoperative period, the most common complications are infection and rotating-hinge dislocation/failure.^3,12 There are various component options available for DFRs, including straight vs curved, cemented vs cementless/press-fit, and long vs short stems.¹³ Studies have sought to elucidate the ideal implant to decrease the rate of complications. Lu and colleagues demonstrated that curved press-fit short stems provided a stable interface without loosening over the short term (2 years) in 42 patients.¹³ No implant failures or incidences of aseptic loosening occurred in their study.¹³

The implant used in this case was a curved press-fit short-stem DFR. It was thought that this patient was young and with good enough bone quality that a press-fit short stem would be best in preserving bone stock. Both the technique guide and literature support reaming 0 to 2 mm greater than the planned stem size to accommodate the implant curvature.¹³ In this case, the intramedullary canal was reamed 0.5 mm larger than the curved stem that was implanted (16 mm and 15.5 mm, respectively). Intraoperatively during the index DFR, the component was stable and seemed to have a good press-fit interface. Despite this, obvious loosening of the component occurred with a relatively low-energy mechanism when the patient kicked the leg onto a chair, causing just enough force and femoral rotation to result in 180° rotation of the component.

Conclusions

We present this case report to make surgeons aware of this rare but serious complication. Although the final implant is a porous and curved stem, careful attention should be made during trialing to use the best-fitting implant to prevent this complication. If an adequate interference fit cannot be obtained, cementing the component may be required to prevent its loosening and catastrophic failure.

Chest pain is one of the most common concerns in patients presenting to the emergency department in the United States, accounting for approximately 7.6 million visits annually.¹ Given the high mortality rate associated with acute coronary syndromes, prompt evaluation of chest pain is essential.² Even in mild cases, recognition of newly onset or worsening coronary artery disease (CAD) is crucial to ensure that patients receive optimal medication therapy.

In symptomatic patients with risk factors for CAD, such as advanced age, hypertension, hyperlipidemia, obesity, and diabetes mellitus, myocardial perfusion imaging (MPI) is frequently used as a modality to assess the presence, location, and severity of ischemic or infarcted myocardium.² MPI requires administration of a radiopharmaceutical before and after the patient undergoes a form of stress.² This radiopharmaceutical is then detected in the myocardium with a nuclear camera, and images are obtained of the heart to assess myocardial blood flow.²

MPI can be performed using exercise-induced stress via a treadmill, or medication-induced stress (Table 1). In both strategies, healthy coronary arteries dilate to provide the myocardium with more blood flow to meet the increasing myocardial oxygen demand during this period of stress. While healthy vessels are able to dilate appropriately, coronary arteries with flow-limiting stenoses are unable to dilate to the same extent in response to stress.² Because radioactive isotope uptake by the myocardium is directly related to arterial blood flow, MPI is able to demonstrate a mismatch in coronary blood flow between healthy and diseased coronary arteries indicated by differences in radioisotope uptake.² The presence of such a mismatch, in conjunction with clinical history, potentially suggests the presence of CAD.

Because nicotine and nicotine replacement therapy (NRT) may have substantial effects on coronary circulation, a current area of controversy is whether these should be stopped prior to the use of a stress-inducing medication during MPI. To date, no formal drug interaction studies have been conducted between nicotine and regadenoson.⁵ Similarly, the ADVANCE MPI 2 Trial, which led to the US Food and Drug Administration approval of regadenoson, did not specify restrictions on the use of nicotine prior to stress testing in the protocol.⁶ However, as this trial was multicenter, investigators admit that individual study sites could have had their own restrictions on the use of nicotine prior to stress testing with regadenoson, but this information was not collected.⁶ The current review focuses on how the simultaneous use of nicotine or NRT during MPI with pharmacologic agents, such as regadenoson, may affect the accuracy of imaging results and the clinical impact of this interaction.

Nicotine Coronary Artery Effect

It is well documented that long-term cigarette smoking is a major risk factor for CAD.⁷ Compared with nonsmokers, cigarette smokers experience 2 times greater risk of morbidity and mortality from ischemic heart disease.⁷ There are several mechanisms by which nicotine induces damage to the myocardium (Figure). Nicotine has direct effects on both the sympathetic nervous system (SNS) and myocardial endothelium.⁸ Together, these factors result in reduced coronary blood flow, leading to less oxygen supply to meet an increased oxygen demand, resulting in myocardial ischemia.

Nicotine’s effect on coronary vasomotor tone occurs primarily through noradrenergic stimulation of α and β receptors associated with coronary vasoconstriction or vasodilation, respectively.^9,10 These competing influences on coronary blood flow appear to manifest differently based on whether patients are at rest or in a stressed state. A study by Czerin and colleagues demonstrated that in healthy patients with relatively short smoking histories and in a healthy nonsmoker control group, coronary blood flow increased by 25% and 40%, respectively, with nicotine use at rest.⁹ However, when these patients were stressed with dipyramidole and while smoking during the examination, myocardial blood flow was reduced by 11% in the study group and 14% in the control group.⁹ This is likely because the patients studied had relatively healthy coronary arteries that were able to maximally dilate when stressed. In this scenario, nicotine’s dilatory effects are offset by nicotine’s α-receptor–mediated vasoconstriction effects.⁹ Of note, patients in the study group experienced a somewhat diminished increase in coronary blood flow at rest with nicotine use, suggesting that even a short smoking history may damage the myocardial endothelium, rendering it less responsive to nicotine’s vasodilatory effects.⁹

Nicotine Replacement Therapy and Stress Testing

Given the association between cigarette smoking and CAD, medical practitioners strongly encourage patients to quit smoking to reduce their risk of adverse cardiovascular outcomes. Various smoking cessation treatments are available for patients. Common, readily accessible forms of therapy include nicotine replacement products (Table 2).

Early studies of NRT in patients with underlying CVD found an increased risk of cardiovascular events, such as myocardial infarction, presumably due to the nicotine content of these products.^13,14 However, the concentration of nicotine in NRT is substantially lower than that found in cigarettes and in some formulations, such as transdermal patches, nicotine is delivered over a prolonged period of time.¹⁵ For this reason, NRT is thought to be safe in patients with underlying CVD and stable ischemic heart disease. A recent systematic review and meta-analysis found that while NRT may be associated with tachycardia, it did not increase the risk of more serious cardiovascular adverse effects (AEs).^16,17

Given the lower nicotine concentration in NRT products, the associated hemodynamic effect of nicotine also is thought to be less pronounced. In a study conducted by Tzivoni and colleagues in patients with CAD using transdermal nicotine patches, no differences in blood pressure, heart rate, ischemia, or arrhythmias were found from baseline to 2 weeks.¹⁸ These findings were further confirmed in a small study by Lucini and colleagues, which found that nicotine patches produced slight hemodynamic effects, but to a lesser extent than cigarette smoking.¹⁹ For the NRT gum formulation, while a small study found that 4 mg produced coronary vasoconstriction in patients with underlying CAD, a study by Nitenberg and Antony demonstrated that healthy and diseased coronary arteries did not significantly constrict while patients were using nicotine gum both before and after a cold pressor test, suggesting a lesser degree of coronary vasoconstriction than nicotine from cigarette smoking.^20,21 Similar findings have been described with the nicotine intranasal spray in a study by Keeley and colleagues, which showed no additional AEs on myocardial demand or vasoconstriction when an intranasal nicotine spray was added to cigarette smoking.²² Importantly, a review of the transdermal and gum formulations found that these less pronounced hemodynamic effects were observed across different doses of NRT; however, further studies are needed to clarify the relationship between NRT dose and cardiovascular effects.²³

Overall, NRT does not seem to activate the SNS to the same degree as nicotine obtained via cigarette smoking and likely does not increase the myocardial oxygen demand as much. Additionally, by containing a lower concentration of nicotine, NRT may not impair the myocardium’s ability to supply oxygen to coronary arteries to the same extent as nicotine from cigarette smoking. Therefore, the effects of NRT on MPI using a stress-inducing medication may not be as pronounced. However, due to study limitations, results should be interpreted cautiously.^18-23

Conclusions

Because of the close relationship between cigarette smoking and CAD, many patients with underlying CVD are either current smokers or may be using NRT for smoking cessation. Therefore, the question of whether to refrain from nicotine use prior to MPI is clinically relevant. Currently, there is a lack of high-quality studies demonstrating the effects of nicotine and NRT on coronary perfusion. Because of this, the impact of nicotine and NRT use on the accuracy of MPI using stress-inducing medications remains uncertain. Nevertheless, given that nicotine and NRT may largely affect the accuracy of imaging results, several institutions have adopted protocols that prohibit patients from using these drugs on the day of nuclear stress testing.

There are currently no data specifying the number of hours to hold nicotine products prior to cardiac stress testing. It is generally recommended that other medications that affect coronary blood flow be held for 5 half-lives before conducting MPI.⁴ Following the same guidance for nicotine and NRT may present a reasonable approach to ensure accurate imaging results. Based on the discussed literature, patients should be instructed to refrain from cigarette smoking for at least 5 to 10 hours prior to MPI, given nicotine’s half-life of about 1 to 2 hours.²⁴

The data for NRT are less clear. While use of NRT may not be an absolute contraindication to conducting MPI, it is important to consider that this may affect the accuracy of results. Given this uncertainty, it is likely ideal to hold NRT prior to MPI, based on the specific formulation of NRT and that product's half-life. Further robust studies are needed to analyze the impact of nicotine and NRT on the accuracy of nuclear stress testing using a medication.

Chest pain is one of the most common concerns in patients presenting to the emergency department in the United States, accounting for approximately 7.6 million visits annually.¹ Given the high mortality rate associated with acute coronary syndromes, prompt evaluation of chest pain is essential.² Even in mild cases, recognition of newly onset or worsening coronary artery disease (CAD) is crucial to ensure that patients receive optimal medication therapy.

In symptomatic patients with risk factors for CAD, such as advanced age, hypertension, hyperlipidemia, obesity, and diabetes mellitus, myocardial perfusion imaging (MPI) is frequently used as a modality to assess the presence, location, and severity of ischemic or infarcted myocardium.² MPI requires administration of a radiopharmaceutical before and after the patient undergoes a form of stress.² This radiopharmaceutical is then detected in the myocardium with a nuclear camera, and images are obtained of the heart to assess myocardial blood flow.²

MPI can be performed using exercise-induced stress via a treadmill, or medication-induced stress (Table 1). In both strategies, healthy coronary arteries dilate to provide the myocardium with more blood flow to meet the increasing myocardial oxygen demand during this period of stress. While healthy vessels are able to dilate appropriately, coronary arteries with flow-limiting stenoses are unable to dilate to the same extent in response to stress.² Because radioactive isotope uptake by the myocardium is directly related to arterial blood flow, MPI is able to demonstrate a mismatch in coronary blood flow between healthy and diseased coronary arteries indicated by differences in radioisotope uptake.² The presence of such a mismatch, in conjunction with clinical history, potentially suggests the presence of CAD.

Because nicotine and nicotine replacement therapy (NRT) may have substantial effects on coronary circulation, a current area of controversy is whether these should be stopped prior to the use of a stress-inducing medication during MPI. To date, no formal drug interaction studies have been conducted between nicotine and regadenoson.⁵ Similarly, the ADVANCE MPI 2 Trial, which led to the US Food and Drug Administration approval of regadenoson, did not specify restrictions on the use of nicotine prior to stress testing in the protocol.⁶ However, as this trial was multicenter, investigators admit that individual study sites could have had their own restrictions on the use of nicotine prior to stress testing with regadenoson, but this information was not collected.⁶ The current review focuses on how the simultaneous use of nicotine or NRT during MPI with pharmacologic agents, such as regadenoson, may affect the accuracy of imaging results and the clinical impact of this interaction.

Nicotine Coronary Artery Effect

It is well documented that long-term cigarette smoking is a major risk factor for CAD.⁷ Compared with nonsmokers, cigarette smokers experience 2 times greater risk of morbidity and mortality from ischemic heart disease.⁷ There are several mechanisms by which nicotine induces damage to the myocardium (Figure). Nicotine has direct effects on both the sympathetic nervous system (SNS) and myocardial endothelium.⁸ Together, these factors result in reduced coronary blood flow, leading to less oxygen supply to meet an increased oxygen demand, resulting in myocardial ischemia.

Nicotine’s effect on coronary vasomotor tone occurs primarily through noradrenergic stimulation of α and β receptors associated with coronary vasoconstriction or vasodilation, respectively.^9,10 These competing influences on coronary blood flow appear to manifest differently based on whether patients are at rest or in a stressed state. A study by Czerin and colleagues demonstrated that in healthy patients with relatively short smoking histories and in a healthy nonsmoker control group, coronary blood flow increased by 25% and 40%, respectively, with nicotine use at rest.⁹ However, when these patients were stressed with dipyramidole and while smoking during the examination, myocardial blood flow was reduced by 11% in the study group and 14% in the control group.⁹ This is likely because the patients studied had relatively healthy coronary arteries that were able to maximally dilate when stressed. In this scenario, nicotine’s dilatory effects are offset by nicotine’s α-receptor–mediated vasoconstriction effects.⁹ Of note, patients in the study group experienced a somewhat diminished increase in coronary blood flow at rest with nicotine use, suggesting that even a short smoking history may damage the myocardial endothelium, rendering it less responsive to nicotine’s vasodilatory effects.⁹

Nicotine Replacement Therapy and Stress Testing

Given the association between cigarette smoking and CAD, medical practitioners strongly encourage patients to quit smoking to reduce their risk of adverse cardiovascular outcomes. Various smoking cessation treatments are available for patients. Common, readily accessible forms of therapy include nicotine replacement products (Table 2).

Early studies of NRT in patients with underlying CVD found an increased risk of cardiovascular events, such as myocardial infarction, presumably due to the nicotine content of these products.^13,14 However, the concentration of nicotine in NRT is substantially lower than that found in cigarettes and in some formulations, such as transdermal patches, nicotine is delivered over a prolonged period of time.¹⁵ For this reason, NRT is thought to be safe in patients with underlying CVD and stable ischemic heart disease. A recent systematic review and meta-analysis found that while NRT may be associated with tachycardia, it did not increase the risk of more serious cardiovascular adverse effects (AEs).^16,17

Given the lower nicotine concentration in NRT products, the associated hemodynamic effect of nicotine also is thought to be less pronounced. In a study conducted by Tzivoni and colleagues in patients with CAD using transdermal nicotine patches, no differences in blood pressure, heart rate, ischemia, or arrhythmias were found from baseline to 2 weeks.¹⁸ These findings were further confirmed in a small study by Lucini and colleagues, which found that nicotine patches produced slight hemodynamic effects, but to a lesser extent than cigarette smoking.¹⁹ For the NRT gum formulation, while a small study found that 4 mg produced coronary vasoconstriction in patients with underlying CAD, a study by Nitenberg and Antony demonstrated that healthy and diseased coronary arteries did not significantly constrict while patients were using nicotine gum both before and after a cold pressor test, suggesting a lesser degree of coronary vasoconstriction than nicotine from cigarette smoking.^20,21 Similar findings have been described with the nicotine intranasal spray in a study by Keeley and colleagues, which showed no additional AEs on myocardial demand or vasoconstriction when an intranasal nicotine spray was added to cigarette smoking.²² Importantly, a review of the transdermal and gum formulations found that these less pronounced hemodynamic effects were observed across different doses of NRT; however, further studies are needed to clarify the relationship between NRT dose and cardiovascular effects.²³

Overall, NRT does not seem to activate the SNS to the same degree as nicotine obtained via cigarette smoking and likely does not increase the myocardial oxygen demand as much. Additionally, by containing a lower concentration of nicotine, NRT may not impair the myocardium’s ability to supply oxygen to coronary arteries to the same extent as nicotine from cigarette smoking. Therefore, the effects of NRT on MPI using a stress-inducing medication may not be as pronounced. However, due to study limitations, results should be interpreted cautiously.^18-23

Conclusions

Because of the close relationship between cigarette smoking and CAD, many patients with underlying CVD are either current smokers or may be using NRT for smoking cessation. Therefore, the question of whether to refrain from nicotine use prior to MPI is clinically relevant. Currently, there is a lack of high-quality studies demonstrating the effects of nicotine and NRT on coronary perfusion. Because of this, the impact of nicotine and NRT use on the accuracy of MPI using stress-inducing medications remains uncertain. Nevertheless, given that nicotine and NRT may largely affect the accuracy of imaging results, several institutions have adopted protocols that prohibit patients from using these drugs on the day of nuclear stress testing.

There are currently no data specifying the number of hours to hold nicotine products prior to cardiac stress testing. It is generally recommended that other medications that affect coronary blood flow be held for 5 half-lives before conducting MPI.⁴ Following the same guidance for nicotine and NRT may present a reasonable approach to ensure accurate imaging results. Based on the discussed literature, patients should be instructed to refrain from cigarette smoking for at least 5 to 10 hours prior to MPI, given nicotine’s half-life of about 1 to 2 hours.²⁴

The data for NRT are less clear. While use of NRT may not be an absolute contraindication to conducting MPI, it is important to consider that this may affect the accuracy of results. Given this uncertainty, it is likely ideal to hold NRT prior to MPI, based on the specific formulation of NRT and that product's half-life. Further robust studies are needed to analyze the impact of nicotine and NRT on the accuracy of nuclear stress testing using a medication.

Chest pain is one of the most common concerns in patients presenting to the emergency department in the United States, accounting for approximately 7.6 million visits annually.¹ Given the high mortality rate associated with acute coronary syndromes, prompt evaluation of chest pain is essential.² Even in mild cases, recognition of newly onset or worsening coronary artery disease (CAD) is crucial to ensure that patients receive optimal medication therapy.

In symptomatic patients with risk factors for CAD, such as advanced age, hypertension, hyperlipidemia, obesity, and diabetes mellitus, myocardial perfusion imaging (MPI) is frequently used as a modality to assess the presence, location, and severity of ischemic or infarcted myocardium.² MPI requires administration of a radiopharmaceutical before and after the patient undergoes a form of stress.² This radiopharmaceutical is then detected in the myocardium with a nuclear camera, and images are obtained of the heart to assess myocardial blood flow.²

MPI can be performed using exercise-induced stress via a treadmill, or medication-induced stress (Table 1). In both strategies, healthy coronary arteries dilate to provide the myocardium with more blood flow to meet the increasing myocardial oxygen demand during this period of stress. While healthy vessels are able to dilate appropriately, coronary arteries with flow-limiting stenoses are unable to dilate to the same extent in response to stress.² Because radioactive isotope uptake by the myocardium is directly related to arterial blood flow, MPI is able to demonstrate a mismatch in coronary blood flow between healthy and diseased coronary arteries indicated by differences in radioisotope uptake.² The presence of such a mismatch, in conjunction with clinical history, potentially suggests the presence of CAD.

Because nicotine and nicotine replacement therapy (NRT) may have substantial effects on coronary circulation, a current area of controversy is whether these should be stopped prior to the use of a stress-inducing medication during MPI. To date, no formal drug interaction studies have been conducted between nicotine and regadenoson.⁵ Similarly, the ADVANCE MPI 2 Trial, which led to the US Food and Drug Administration approval of regadenoson, did not specify restrictions on the use of nicotine prior to stress testing in the protocol.⁶ However, as this trial was multicenter, investigators admit that individual study sites could have had their own restrictions on the use of nicotine prior to stress testing with regadenoson, but this information was not collected.⁶ The current review focuses on how the simultaneous use of nicotine or NRT during MPI with pharmacologic agents, such as regadenoson, may affect the accuracy of imaging results and the clinical impact of this interaction.

Nicotine Coronary Artery Effect

It is well documented that long-term cigarette smoking is a major risk factor for CAD.⁷ Compared with nonsmokers, cigarette smokers experience 2 times greater risk of morbidity and mortality from ischemic heart disease.⁷ There are several mechanisms by which nicotine induces damage to the myocardium (Figure). Nicotine has direct effects on both the sympathetic nervous system (SNS) and myocardial endothelium.⁸ Together, these factors result in reduced coronary blood flow, leading to less oxygen supply to meet an increased oxygen demand, resulting in myocardial ischemia.

Nicotine’s effect on coronary vasomotor tone occurs primarily through noradrenergic stimulation of α and β receptors associated with coronary vasoconstriction or vasodilation, respectively.^9,10 These competing influences on coronary blood flow appear to manifest differently based on whether patients are at rest or in a stressed state. A study by Czerin and colleagues demonstrated that in healthy patients with relatively short smoking histories and in a healthy nonsmoker control group, coronary blood flow increased by 25% and 40%, respectively, with nicotine use at rest.⁹ However, when these patients were stressed with dipyramidole and while smoking during the examination, myocardial blood flow was reduced by 11% in the study group and 14% in the control group.⁹ This is likely because the patients studied had relatively healthy coronary arteries that were able to maximally dilate when stressed. In this scenario, nicotine’s dilatory effects are offset by nicotine’s α-receptor–mediated vasoconstriction effects.⁹ Of note, patients in the study group experienced a somewhat diminished increase in coronary blood flow at rest with nicotine use, suggesting that even a short smoking history may damage the myocardial endothelium, rendering it less responsive to nicotine’s vasodilatory effects.⁹

Nicotine Replacement Therapy and Stress Testing

Given the association between cigarette smoking and CAD, medical practitioners strongly encourage patients to quit smoking to reduce their risk of adverse cardiovascular outcomes. Various smoking cessation treatments are available for patients. Common, readily accessible forms of therapy include nicotine replacement products (Table 2).

Early studies of NRT in patients with underlying CVD found an increased risk of cardiovascular events, such as myocardial infarction, presumably due to the nicotine content of these products.^13,14 However, the concentration of nicotine in NRT is substantially lower than that found in cigarettes and in some formulations, such as transdermal patches, nicotine is delivered over a prolonged period of time.¹⁵ For this reason, NRT is thought to be safe in patients with underlying CVD and stable ischemic heart disease. A recent systematic review and meta-analysis found that while NRT may be associated with tachycardia, it did not increase the risk of more serious cardiovascular adverse effects (AEs).^16,17

Given the lower nicotine concentration in NRT products, the associated hemodynamic effect of nicotine also is thought to be less pronounced. In a study conducted by Tzivoni and colleagues in patients with CAD using transdermal nicotine patches, no differences in blood pressure, heart rate, ischemia, or arrhythmias were found from baseline to 2 weeks.¹⁸ These findings were further confirmed in a small study by Lucini and colleagues, which found that nicotine patches produced slight hemodynamic effects, but to a lesser extent than cigarette smoking.¹⁹ For the NRT gum formulation, while a small study found that 4 mg produced coronary vasoconstriction in patients with underlying CAD, a study by Nitenberg and Antony demonstrated that healthy and diseased coronary arteries did not significantly constrict while patients were using nicotine gum both before and after a cold pressor test, suggesting a lesser degree of coronary vasoconstriction than nicotine from cigarette smoking.^20,21 Similar findings have been described with the nicotine intranasal spray in a study by Keeley and colleagues, which showed no additional AEs on myocardial demand or vasoconstriction when an intranasal nicotine spray was added to cigarette smoking.²² Importantly, a review of the transdermal and gum formulations found that these less pronounced hemodynamic effects were observed across different doses of NRT; however, further studies are needed to clarify the relationship between NRT dose and cardiovascular effects.²³

Overall, NRT does not seem to activate the SNS to the same degree as nicotine obtained via cigarette smoking and likely does not increase the myocardial oxygen demand as much. Additionally, by containing a lower concentration of nicotine, NRT may not impair the myocardium’s ability to supply oxygen to coronary arteries to the same extent as nicotine from cigarette smoking. Therefore, the effects of NRT on MPI using a stress-inducing medication may not be as pronounced. However, due to study limitations, results should be interpreted cautiously.^18-23

Conclusions

Because of the close relationship between cigarette smoking and CAD, many patients with underlying CVD are either current smokers or may be using NRT for smoking cessation. Therefore, the question of whether to refrain from nicotine use prior to MPI is clinically relevant. Currently, there is a lack of high-quality studies demonstrating the effects of nicotine and NRT on coronary perfusion. Because of this, the impact of nicotine and NRT use on the accuracy of MPI using stress-inducing medications remains uncertain. Nevertheless, given that nicotine and NRT may largely affect the accuracy of imaging results, several institutions have adopted protocols that prohibit patients from using these drugs on the day of nuclear stress testing.

There are currently no data specifying the number of hours to hold nicotine products prior to cardiac stress testing. It is generally recommended that other medications that affect coronary blood flow be held for 5 half-lives before conducting MPI.⁴ Following the same guidance for nicotine and NRT may present a reasonable approach to ensure accurate imaging results. Based on the discussed literature, patients should be instructed to refrain from cigarette smoking for at least 5 to 10 hours prior to MPI, given nicotine’s half-life of about 1 to 2 hours.²⁴

The data for NRT are less clear. While use of NRT may not be an absolute contraindication to conducting MPI, it is important to consider that this may affect the accuracy of results. Given this uncertainty, it is likely ideal to hold NRT prior to MPI, based on the specific formulation of NRT and that product's half-life. Further robust studies are needed to analyze the impact of nicotine and NRT on the accuracy of nuclear stress testing using a medication.

Suicide is a national public health concern that affects thousands of US individuals and families, with repercussions that reverberate through entire communities. In 2019, there were 47,500 US deaths by suicide, which accounted for about 1 death every 11 minutes.¹ Suicide remains the tenth leading cause of death in the United States and has been part of the top 12 leading causes of death since 1975.² Unfortunately, this trend has worsened; suicide rates have increased by 35% from 1999 to 2018.³ One particularly vulnerable population is US veterans who accounted for 13.8% of all suicide deaths in 2018.⁴ Among veterans, the suicide death average increased from 16.6 per day in 2005 to 17.6 in 2018.⁴ Furthermore, veterans experiencing homelessness are 5 times more likely to attempt suicide and 2.5 times more likely to have suicidal ideation compared with veterans without a history of homelessness.⁴ Suicide is a significant issue among veterans experiencing homelessness: Veterans account for about 11% of the overall US homeless population.⁵

Recent data suggest opportunities for suicide risk assessment in the primary care setting. A study from the Veterans Health Administration (VHA) Office for Suicide Prevention found that in 2014 an average of 20 veterans died by suicide every day and 6 of the 20 (30%) on average used VHA services within the prior year.⁶ Similarly, a review of 40 studies on suicide found that 45% of suicide victims had contact with their primary care practitioner (PCP) within 1 month of suicide, and 75% of victims had contact within the year of suicide.⁷ An analysis of depression screening in 2008/2009 using Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) at 3 large western US Department of Veterans Affairs (VA) medical centers found that 55% were screened for depression.⁸ The VA has made suicide prevention a top priority and supports the established US goal of reducing annual suicide deaths by 20% by 2025.⁹ Given key opportunities for suicide risk assessment in the primary care setting, the VHA Office of Mental Health and Suicide Prevention implemented a national, standardized process for suicide risk assessment on October 1, 2018.^10,11

The VA approach to suicide screening, evaluation, and documentation has evolved over time. Between October 2018 and December 2020, the process was augmented to include 3 stages embedded into the electronic health record (EHR): a primary screen (PHQ-2 with Item 9 from the PHQ-9 [PHQ-2+I9]), a secondary screen (Columbia-Suicide Severity Rating Scale [C-SSRS]), and a tertiary screen (Comprehensive Suicide Risk Evaluation [CSRE]). The primary screen consisted of the depression screening using the PHQ-2 with the addition of I9 asking about suicidal ideation. The secondary screening, or C-SSRS, included 8 questions to elaborate on suicidal ideation, intent, plan, and any history of suicidal attempts or preparatory behaviors. The tertiary screen consisted of the CSRE, a questionnaire developed internally by the VA in 2018 to further evaluate the veteran’s suicidal thoughts, attempts, warning signs, risk factors, protective factors, and reasons for living. The goal of the screenings was to identify veterans at risk of suicide, assess risk severity, and to individually tailor risk mitigation strategies for safe disposition. These risk categories were developed by the regional Mental Illness Research, Education and Clinical Center, which suggested treatment strategies, such as hospitalization or close outpatient follow-up.^12,13

The Homeless Patient Aligned Care Team (HPACT) clinic at the West Los Angeles VA Medical Center (WLAVAMC) in California, one of the largest VA homeless clinics in the country and 1 of 7 national VA Office of Academic Affiliation Centers of Excellence in Primary Care Education training programs implemented the standardized tools for suicide risk screening and quality improvement (QI). The HPACT clinic is an interprofessional team, including primary care, mental health, social work, pharmacy, and peer support, that is adjacent to the WLAVAMC general primary care clinics. The team collaboratively addresses both medical and psychosocial needs of veterans with a focus on the Housing First Model, an approach that prioritizes ending homelessness while addressing all factors associated with veterans' health and well-being. After 1 year of stable housing, veterans graduate to the WLAVAMC general primary care clinics.

Given the vulnerability of veterans experiencing homelessness, the clinic leadership identified suicide risk screening as a high priority initiative and created a taskforce to oversee effective implementation of clinic screening efforts. An interprofessional team of nurse practitioners (NPs), pharmacists, physicians, psychologists, social workers (SWs), and trainees formed to improve screening efforts and use the QI principles to guide analysis and intervention. The team wrote the following SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) Aim statements: (1) ensure > 90% of eligible patients receive a primary screen; (2) ensure > 90% of positive primary I9 screens receive subsequent screenings within 24 hours; and (3) increase staff comfort and familiarity using the screening tools. This article examines the results of the screening initiative 1-year postimplementation, describes difficulties faced, and suggests strategies that might be used to overcome those challenges.

Methods

This QI analysis was exempt from institutional review board review. Prior to the standardized national suicide risk assessment rollout of October 1, 2018, the QI team met to review and understand the workflow to be implemented into the HPACT clinic. To describe the initial screening process, the new suicide risk assessment consisted of primary, secondary, and tertiary screens that would warrant subsequent intervention by clinicians if positive (Figure 1). The primary screen included the PHQ-2+I9 questionnaire (PHQ-2 for depression and I9 for suicidal ideation). If either were positive, follow-up questionnaires were required. Of note, patients with a prior depression diagnosis, cognitive impairment defined at a severity of moderate or greater based on clinician evaluation and judgement, or life expectancy < 6 months were exempt from screening because, by definition, they had theoretically already been screened and classified as under surveillance.

A positive I9 response prompted a secondary screen using C-SSRS. A positive secondary screen prompted a tertiary screen using CSRE. If the PHQ-2 screening was positive but I9 was negative, the standard follow-up depression clinical reminder was used. Any clinical staff member could perform the primary screen, including licensed vocational nurses (LVNs), registered nurses (RNs), and SWs in any setting (eg, emergency department, primary care, inpatient services). The secondary and tertiary screens required completion by a licensed clinician. RNs were able to perform the secondary screen but not the tertiary screen.

The HPACT clinic serves approximately 3000 patients by 50 staff and trainees divided into 2 teams. LVNs and RNs were tasked to conduct the primary screen as part of their initial clinic check-in. If the primary screen was positive for scheduled patients, LVNs notified a PCP to complete the secondary screen. For unscheduled patients, RNs conducted a primary screen and, if positive, a secondary screen. If the secondary screen was positive, a tertiary screen was performed by mental health practitioners or SWs, or PCPs if the former were unavailable. SWs, mental health practitioners, and PCPs were colocated in the clinic, which allowed for safe and convenient warm handoffs between clinicians.

Results

During the project year, the HPACT clinic had 2932 unique patients assigned to primary care. Of those veterans, 533 (18%) were exempt from screening by protocol. Of the remainder, staff screened 1876 (64%) of eligible veterans for suicide risk (Figure 2), which did not meet the SMART Aim of screening > 90% of eligible veterans. For the follow-up screens, using a QI dashboard designed for reviewing I9 and C-SSRS results, the QI team reviewed a convenience sample of 5 provider panels and identified 34 positive I9 screens. Twenty of those 34 patients (59%) received a C-SSRS within 24 hours of the positive I9, which did not meet the SMART Aim of ensuring > 90% of primary I9 screens had subsequent C-SSRS screening within 24 hours.

Of the veterans screened, 1,271 (43%) had their screening performed outside of the HPACT primary care team assigned, while 605 (21%) patients had their screening performed by an HPACT member. Most of the screening that occurred outside of the assigned primary care team occurred in other physical settings, including other VA facilities.

Of the 523 (18%) patients who were not screened, 331 (11%) patients had no visit to the HPACT clinic and 132 (5%) empaneled patients did not visit any VA site within the 1-year period. There were 192 (7%) patients who were not screened that had a visit to HPACT while 19 (1%) of those patients declined screening. A total of 184 (6%) patients were not screened and thus were considered true missed opportunities. This group of patients were eligible for screening but did not undergo screening in the HPACT clinic or any other VA setting despite visiting the VA.

Discussion

Though the QI project failed to meet the SMART Aim of ensuring > 90% of eligible patients received a primary screen for suicide risk and > 90% of positive primary I9 screens received subsequent screenings within 24 hours, the results highlight effective practices and barriers for implementation of wide-scale EHR-based interventions for suicide assessment. Most missed screening opportunities were due to patients being lost to follow-up over the duration of the project, which is a challenge faced in this patient population. A recent analysis of the national rollout of this screening program found that 95% of eligible veterans with a visit to the VA in the first year of the program received screening.¹⁴ In a post hoc analysis using the same eligibility criteria, the rate of screening for this project was 83%. Reflecting on the data from this national cohort compared with the HPACT clinic, this brings to light potential circumstances that may be unique to veterans experiencing homelessness compared with the general veteran population, for instance, the level of engagement may be lower among veterans experiencing homelessness, though this is beyond the scope of this article. Nonetheless, promoting interprofessional collaboration, visualizing effective process flows, establishing clear lines of communication and roles for involved staff, and opening avenues for continuous feedback and troubleshooting are all potentially effective interventions to improve suicide screening rates within the veteran population.

This HPACT clinic initiative aimed to determine how a new screening process would be implemented while identifying potential areas for improvement. Surprisingly, 43% of patients who were screened had their screening performed outside of the HPACT clinic, most often in the inpatient setting at other WLAVAMC clinics or other VA systems. It is possible that due to the nature of the patient population that the HPACT clinic serves with intensive service needs, these patients have wider geographic and clinical location use than most clinic populations due to the transient nature of patients with housing insecurity. What is encouraging, however, is that through this systemwide initiative, there is an impetus to screen veterans, regardless of who performs the screening. This is particularly meaningful given that rates of depression screening may be as low as 4% among PCPs.¹⁵ During implementation, the QI team learned that nearly 18% of the empaneled HPACT patients were exempt from screening. The exempt patients do not have an active clinical reminder for depression screens. Instead, these patients are receiving mental health surveillance and specialty treatment, during which continuous monitoring and assessment for suicidal ideation and risk of suicide are performed. Additionally, an EHR-based factor that also may limit appropriate follow-up and contribute to missed opportunities is that secondary and tertiary screens do not populate until the EHR was refreshed after positive primary screens, which introduces human error in a process that could be automated. Both RNs and PCPs may occasionally miss secondary and tertiary screens due to this issue, which continues to be a barrier. Given the high risk HPACT clinic population, the QI team encouraged staff members to frequently screen patients for suicidal ideation regardless of clinical reminders. A consideration for the future would be to identify optimal frequency for screening and to continue to validate assessment methods.

Limitations

Due to the limited sample size, findings cannot be generalized to all VA sites. The QI team used retrospective, administrative data. Additionally, since this is a primary care clinic focused on a specialized population, this result may not be generalizable to all primary care settings, other primary care populations, or even other homeless primary care clinics, though it may establish a benchmark when other clinics internally examine their data and processes.

Conclusions

Improving screening protocols can lead to identification of at-risk individuals who would not have otherwise been identified.^16,17 As the US continues to grapple with mental health and suicide, efforts toward addressing this important issue among veterans remains a top priority.

Acknowledgments

Thank you to the VAGLAHS Center of Excellence in Primary Care Education faculty and trainees, the HPACT staff, and the VA Informatics and Computing Infrastructure (VINCI) for data support.

Suicide is a national public health concern that affects thousands of US individuals and families, with repercussions that reverberate through entire communities. In 2019, there were 47,500 US deaths by suicide, which accounted for about 1 death every 11 minutes.¹ Suicide remains the tenth leading cause of death in the United States and has been part of the top 12 leading causes of death since 1975.² Unfortunately, this trend has worsened; suicide rates have increased by 35% from 1999 to 2018.³ One particularly vulnerable population is US veterans who accounted for 13.8% of all suicide deaths in 2018.⁴ Among veterans, the suicide death average increased from 16.6 per day in 2005 to 17.6 in 2018.⁴ Furthermore, veterans experiencing homelessness are 5 times more likely to attempt suicide and 2.5 times more likely to have suicidal ideation compared with veterans without a history of homelessness.⁴ Suicide is a significant issue among veterans experiencing homelessness: Veterans account for about 11% of the overall US homeless population.⁵

Recent data suggest opportunities for suicide risk assessment in the primary care setting. A study from the Veterans Health Administration (VHA) Office for Suicide Prevention found that in 2014 an average of 20 veterans died by suicide every day and 6 of the 20 (30%) on average used VHA services within the prior year.⁶ Similarly, a review of 40 studies on suicide found that 45% of suicide victims had contact with their primary care practitioner (PCP) within 1 month of suicide, and 75% of victims had contact within the year of suicide.⁷ An analysis of depression screening in 2008/2009 using Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) at 3 large western US Department of Veterans Affairs (VA) medical centers found that 55% were screened for depression.⁸ The VA has made suicide prevention a top priority and supports the established US goal of reducing annual suicide deaths by 20% by 2025.⁹ Given key opportunities for suicide risk assessment in the primary care setting, the VHA Office of Mental Health and Suicide Prevention implemented a national, standardized process for suicide risk assessment on October 1, 2018.^10,11

The VA approach to suicide screening, evaluation, and documentation has evolved over time. Between October 2018 and December 2020, the process was augmented to include 3 stages embedded into the electronic health record (EHR): a primary screen (PHQ-2 with Item 9 from the PHQ-9 [PHQ-2+I9]), a secondary screen (Columbia-Suicide Severity Rating Scale [C-SSRS]), and a tertiary screen (Comprehensive Suicide Risk Evaluation [CSRE]). The primary screen consisted of the depression screening using the PHQ-2 with the addition of I9 asking about suicidal ideation. The secondary screening, or C-SSRS, included 8 questions to elaborate on suicidal ideation, intent, plan, and any history of suicidal attempts or preparatory behaviors. The tertiary screen consisted of the CSRE, a questionnaire developed internally by the VA in 2018 to further evaluate the veteran’s suicidal thoughts, attempts, warning signs, risk factors, protective factors, and reasons for living. The goal of the screenings was to identify veterans at risk of suicide, assess risk severity, and to individually tailor risk mitigation strategies for safe disposition. These risk categories were developed by the regional Mental Illness Research, Education and Clinical Center, which suggested treatment strategies, such as hospitalization or close outpatient follow-up.^12,13

The Homeless Patient Aligned Care Team (HPACT) clinic at the West Los Angeles VA Medical Center (WLAVAMC) in California, one of the largest VA homeless clinics in the country and 1 of 7 national VA Office of Academic Affiliation Centers of Excellence in Primary Care Education training programs implemented the standardized tools for suicide risk screening and quality improvement (QI). The HPACT clinic is an interprofessional team, including primary care, mental health, social work, pharmacy, and peer support, that is adjacent to the WLAVAMC general primary care clinics. The team collaboratively addresses both medical and psychosocial needs of veterans with a focus on the Housing First Model, an approach that prioritizes ending homelessness while addressing all factors associated with veterans' health and well-being. After 1 year of stable housing, veterans graduate to the WLAVAMC general primary care clinics.

Given the vulnerability of veterans experiencing homelessness, the clinic leadership identified suicide risk screening as a high priority initiative and created a taskforce to oversee effective implementation of clinic screening efforts. An interprofessional team of nurse practitioners (NPs), pharmacists, physicians, psychologists, social workers (SWs), and trainees formed to improve screening efforts and use the QI principles to guide analysis and intervention. The team wrote the following SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) Aim statements: (1) ensure > 90% of eligible patients receive a primary screen; (2) ensure > 90% of positive primary I9 screens receive subsequent screenings within 24 hours; and (3) increase staff comfort and familiarity using the screening tools. This article examines the results of the screening initiative 1-year postimplementation, describes difficulties faced, and suggests strategies that might be used to overcome those challenges.

Methods

This QI analysis was exempt from institutional review board review. Prior to the standardized national suicide risk assessment rollout of October 1, 2018, the QI team met to review and understand the workflow to be implemented into the HPACT clinic. To describe the initial screening process, the new suicide risk assessment consisted of primary, secondary, and tertiary screens that would warrant subsequent intervention by clinicians if positive (Figure 1). The primary screen included the PHQ-2+I9 questionnaire (PHQ-2 for depression and I9 for suicidal ideation). If either were positive, follow-up questionnaires were required. Of note, patients with a prior depression diagnosis, cognitive impairment defined at a severity of moderate or greater based on clinician evaluation and judgement, or life expectancy < 6 months were exempt from screening because, by definition, they had theoretically already been screened and classified as under surveillance.

A positive I9 response prompted a secondary screen using C-SSRS. A positive secondary screen prompted a tertiary screen using CSRE. If the PHQ-2 screening was positive but I9 was negative, the standard follow-up depression clinical reminder was used. Any clinical staff member could perform the primary screen, including licensed vocational nurses (LVNs), registered nurses (RNs), and SWs in any setting (eg, emergency department, primary care, inpatient services). The secondary and tertiary screens required completion by a licensed clinician. RNs were able to perform the secondary screen but not the tertiary screen.

The HPACT clinic serves approximately 3000 patients by 50 staff and trainees divided into 2 teams. LVNs and RNs were tasked to conduct the primary screen as part of their initial clinic check-in. If the primary screen was positive for scheduled patients, LVNs notified a PCP to complete the secondary screen. For unscheduled patients, RNs conducted a primary screen and, if positive, a secondary screen. If the secondary screen was positive, a tertiary screen was performed by mental health practitioners or SWs, or PCPs if the former were unavailable. SWs, mental health practitioners, and PCPs were colocated in the clinic, which allowed for safe and convenient warm handoffs between clinicians.

Results

During the project year, the HPACT clinic had 2932 unique patients assigned to primary care. Of those veterans, 533 (18%) were exempt from screening by protocol. Of the remainder, staff screened 1876 (64%) of eligible veterans for suicide risk (Figure 2), which did not meet the SMART Aim of screening > 90% of eligible veterans. For the follow-up screens, using a QI dashboard designed for reviewing I9 and C-SSRS results, the QI team reviewed a convenience sample of 5 provider panels and identified 34 positive I9 screens. Twenty of those 34 patients (59%) received a C-SSRS within 24 hours of the positive I9, which did not meet the SMART Aim of ensuring > 90% of primary I9 screens had subsequent C-SSRS screening within 24 hours.

Of the veterans screened, 1,271 (43%) had their screening performed outside of the HPACT primary care team assigned, while 605 (21%) patients had their screening performed by an HPACT member. Most of the screening that occurred outside of the assigned primary care team occurred in other physical settings, including other VA facilities.

Of the 523 (18%) patients who were not screened, 331 (11%) patients had no visit to the HPACT clinic and 132 (5%) empaneled patients did not visit any VA site within the 1-year period. There were 192 (7%) patients who were not screened that had a visit to HPACT while 19 (1%) of those patients declined screening. A total of 184 (6%) patients were not screened and thus were considered true missed opportunities. This group of patients were eligible for screening but did not undergo screening in the HPACT clinic or any other VA setting despite visiting the VA.

Discussion

Though the QI project failed to meet the SMART Aim of ensuring > 90% of eligible patients received a primary screen for suicide risk and > 90% of positive primary I9 screens received subsequent screenings within 24 hours, the results highlight effective practices and barriers for implementation of wide-scale EHR-based interventions for suicide assessment. Most missed screening opportunities were due to patients being lost to follow-up over the duration of the project, which is a challenge faced in this patient population. A recent analysis of the national rollout of this screening program found that 95% of eligible veterans with a visit to the VA in the first year of the program received screening.¹⁴ In a post hoc analysis using the same eligibility criteria, the rate of screening for this project was 83%. Reflecting on the data from this national cohort compared with the HPACT clinic, this brings to light potential circumstances that may be unique to veterans experiencing homelessness compared with the general veteran population, for instance, the level of engagement may be lower among veterans experiencing homelessness, though this is beyond the scope of this article. Nonetheless, promoting interprofessional collaboration, visualizing effective process flows, establishing clear lines of communication and roles for involved staff, and opening avenues for continuous feedback and troubleshooting are all potentially effective interventions to improve suicide screening rates within the veteran population.

This HPACT clinic initiative aimed to determine how a new screening process would be implemented while identifying potential areas for improvement. Surprisingly, 43% of patients who were screened had their screening performed outside of the HPACT clinic, most often in the inpatient setting at other WLAVAMC clinics or other VA systems. It is possible that due to the nature of the patient population that the HPACT clinic serves with intensive service needs, these patients have wider geographic and clinical location use than most clinic populations due to the transient nature of patients with housing insecurity. What is encouraging, however, is that through this systemwide initiative, there is an impetus to screen veterans, regardless of who performs the screening. This is particularly meaningful given that rates of depression screening may be as low as 4% among PCPs.¹⁵ During implementation, the QI team learned that nearly 18% of the empaneled HPACT patients were exempt from screening. The exempt patients do not have an active clinical reminder for depression screens. Instead, these patients are receiving mental health surveillance and specialty treatment, during which continuous monitoring and assessment for suicidal ideation and risk of suicide are performed. Additionally, an EHR-based factor that also may limit appropriate follow-up and contribute to missed opportunities is that secondary and tertiary screens do not populate until the EHR was refreshed after positive primary screens, which introduces human error in a process that could be automated. Both RNs and PCPs may occasionally miss secondary and tertiary screens due to this issue, which continues to be a barrier. Given the high risk HPACT clinic population, the QI team encouraged staff members to frequently screen patients for suicidal ideation regardless of clinical reminders. A consideration for the future would be to identify optimal frequency for screening and to continue to validate assessment methods.

Limitations

Due to the limited sample size, findings cannot be generalized to all VA sites. The QI team used retrospective, administrative data. Additionally, since this is a primary care clinic focused on a specialized population, this result may not be generalizable to all primary care settings, other primary care populations, or even other homeless primary care clinics, though it may establish a benchmark when other clinics internally examine their data and processes.

Conclusions

Improving screening protocols can lead to identification of at-risk individuals who would not have otherwise been identified.^16,17 As the US continues to grapple with mental health and suicide, efforts toward addressing this important issue among veterans remains a top priority.

Acknowledgments

Thank you to the VAGLAHS Center of Excellence in Primary Care Education faculty and trainees, the HPACT staff, and the VA Informatics and Computing Infrastructure (VINCI) for data support.

Suicide is a national public health concern that affects thousands of US individuals and families, with repercussions that reverberate through entire communities. In 2019, there were 47,500 US deaths by suicide, which accounted for about 1 death every 11 minutes.¹ Suicide remains the tenth leading cause of death in the United States and has been part of the top 12 leading causes of death since 1975.² Unfortunately, this trend has worsened; suicide rates have increased by 35% from 1999 to 2018.³ One particularly vulnerable population is US veterans who accounted for 13.8% of all suicide deaths in 2018.⁴ Among veterans, the suicide death average increased from 16.6 per day in 2005 to 17.6 in 2018.⁴ Furthermore, veterans experiencing homelessness are 5 times more likely to attempt suicide and 2.5 times more likely to have suicidal ideation compared with veterans without a history of homelessness.⁴ Suicide is a significant issue among veterans experiencing homelessness: Veterans account for about 11% of the overall US homeless population.⁵

Recent data suggest opportunities for suicide risk assessment in the primary care setting. A study from the Veterans Health Administration (VHA) Office for Suicide Prevention found that in 2014 an average of 20 veterans died by suicide every day and 6 of the 20 (30%) on average used VHA services within the prior year.⁶ Similarly, a review of 40 studies on suicide found that 45% of suicide victims had contact with their primary care practitioner (PCP) within 1 month of suicide, and 75% of victims had contact within the year of suicide.⁷ An analysis of depression screening in 2008/2009 using Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) at 3 large western US Department of Veterans Affairs (VA) medical centers found that 55% were screened for depression.⁸ The VA has made suicide prevention a top priority and supports the established US goal of reducing annual suicide deaths by 20% by 2025.⁹ Given key opportunities for suicide risk assessment in the primary care setting, the VHA Office of Mental Health and Suicide Prevention implemented a national, standardized process for suicide risk assessment on October 1, 2018.^10,11

The VA approach to suicide screening, evaluation, and documentation has evolved over time. Between October 2018 and December 2020, the process was augmented to include 3 stages embedded into the electronic health record (EHR): a primary screen (PHQ-2 with Item 9 from the PHQ-9 [PHQ-2+I9]), a secondary screen (Columbia-Suicide Severity Rating Scale [C-SSRS]), and a tertiary screen (Comprehensive Suicide Risk Evaluation [CSRE]). The primary screen consisted of the depression screening using the PHQ-2 with the addition of I9 asking about suicidal ideation. The secondary screening, or C-SSRS, included 8 questions to elaborate on suicidal ideation, intent, plan, and any history of suicidal attempts or preparatory behaviors. The tertiary screen consisted of the CSRE, a questionnaire developed internally by the VA in 2018 to further evaluate the veteran’s suicidal thoughts, attempts, warning signs, risk factors, protective factors, and reasons for living. The goal of the screenings was to identify veterans at risk of suicide, assess risk severity, and to individually tailor risk mitigation strategies for safe disposition. These risk categories were developed by the regional Mental Illness Research, Education and Clinical Center, which suggested treatment strategies, such as hospitalization or close outpatient follow-up.^12,13

The Homeless Patient Aligned Care Team (HPACT) clinic at the West Los Angeles VA Medical Center (WLAVAMC) in California, one of the largest VA homeless clinics in the country and 1 of 7 national VA Office of Academic Affiliation Centers of Excellence in Primary Care Education training programs implemented the standardized tools for suicide risk screening and quality improvement (QI). The HPACT clinic is an interprofessional team, including primary care, mental health, social work, pharmacy, and peer support, that is adjacent to the WLAVAMC general primary care clinics. The team collaboratively addresses both medical and psychosocial needs of veterans with a focus on the Housing First Model, an approach that prioritizes ending homelessness while addressing all factors associated with veterans' health and well-being. After 1 year of stable housing, veterans graduate to the WLAVAMC general primary care clinics.

Given the vulnerability of veterans experiencing homelessness, the clinic leadership identified suicide risk screening as a high priority initiative and created a taskforce to oversee effective implementation of clinic screening efforts. An interprofessional team of nurse practitioners (NPs), pharmacists, physicians, psychologists, social workers (SWs), and trainees formed to improve screening efforts and use the QI principles to guide analysis and intervention. The team wrote the following SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) Aim statements: (1) ensure > 90% of eligible patients receive a primary screen; (2) ensure > 90% of positive primary I9 screens receive subsequent screenings within 24 hours; and (3) increase staff comfort and familiarity using the screening tools. This article examines the results of the screening initiative 1-year postimplementation, describes difficulties faced, and suggests strategies that might be used to overcome those challenges.

Methods

This QI analysis was exempt from institutional review board review. Prior to the standardized national suicide risk assessment rollout of October 1, 2018, the QI team met to review and understand the workflow to be implemented into the HPACT clinic. To describe the initial screening process, the new suicide risk assessment consisted of primary, secondary, and tertiary screens that would warrant subsequent intervention by clinicians if positive (Figure 1). The primary screen included the PHQ-2+I9 questionnaire (PHQ-2 for depression and I9 for suicidal ideation). If either were positive, follow-up questionnaires were required. Of note, patients with a prior depression diagnosis, cognitive impairment defined at a severity of moderate or greater based on clinician evaluation and judgement, or life expectancy < 6 months were exempt from screening because, by definition, they had theoretically already been screened and classified as under surveillance.

A positive I9 response prompted a secondary screen using C-SSRS. A positive secondary screen prompted a tertiary screen using CSRE. If the PHQ-2 screening was positive but I9 was negative, the standard follow-up depression clinical reminder was used. Any clinical staff member could perform the primary screen, including licensed vocational nurses (LVNs), registered nurses (RNs), and SWs in any setting (eg, emergency department, primary care, inpatient services). The secondary and tertiary screens required completion by a licensed clinician. RNs were able to perform the secondary screen but not the tertiary screen.

The HPACT clinic serves approximately 3000 patients by 50 staff and trainees divided into 2 teams. LVNs and RNs were tasked to conduct the primary screen as part of their initial clinic check-in. If the primary screen was positive for scheduled patients, LVNs notified a PCP to complete the secondary screen. For unscheduled patients, RNs conducted a primary screen and, if positive, a secondary screen. If the secondary screen was positive, a tertiary screen was performed by mental health practitioners or SWs, or PCPs if the former were unavailable. SWs, mental health practitioners, and PCPs were colocated in the clinic, which allowed for safe and convenient warm handoffs between clinicians.

Results

During the project year, the HPACT clinic had 2932 unique patients assigned to primary care. Of those veterans, 533 (18%) were exempt from screening by protocol. Of the remainder, staff screened 1876 (64%) of eligible veterans for suicide risk (Figure 2), which did not meet the SMART Aim of screening > 90% of eligible veterans. For the follow-up screens, using a QI dashboard designed for reviewing I9 and C-SSRS results, the QI team reviewed a convenience sample of 5 provider panels and identified 34 positive I9 screens. Twenty of those 34 patients (59%) received a C-SSRS within 24 hours of the positive I9, which did not meet the SMART Aim of ensuring > 90% of primary I9 screens had subsequent C-SSRS screening within 24 hours.

Of the veterans screened, 1,271 (43%) had their screening performed outside of the HPACT primary care team assigned, while 605 (21%) patients had their screening performed by an HPACT member. Most of the screening that occurred outside of the assigned primary care team occurred in other physical settings, including other VA facilities.

Of the 523 (18%) patients who were not screened, 331 (11%) patients had no visit to the HPACT clinic and 132 (5%) empaneled patients did not visit any VA site within the 1-year period. There were 192 (7%) patients who were not screened that had a visit to HPACT while 19 (1%) of those patients declined screening. A total of 184 (6%) patients were not screened and thus were considered true missed opportunities. This group of patients were eligible for screening but did not undergo screening in the HPACT clinic or any other VA setting despite visiting the VA.

Discussion

Though the QI project failed to meet the SMART Aim of ensuring > 90% of eligible patients received a primary screen for suicide risk and > 90% of positive primary I9 screens received subsequent screenings within 24 hours, the results highlight effective practices and barriers for implementation of wide-scale EHR-based interventions for suicide assessment. Most missed screening opportunities were due to patients being lost to follow-up over the duration of the project, which is a challenge faced in this patient population. A recent analysis of the national rollout of this screening program found that 95% of eligible veterans with a visit to the VA in the first year of the program received screening.¹⁴ In a post hoc analysis using the same eligibility criteria, the rate of screening for this project was 83%. Reflecting on the data from this national cohort compared with the HPACT clinic, this brings to light potential circumstances that may be unique to veterans experiencing homelessness compared with the general veteran population, for instance, the level of engagement may be lower among veterans experiencing homelessness, though this is beyond the scope of this article. Nonetheless, promoting interprofessional collaboration, visualizing effective process flows, establishing clear lines of communication and roles for involved staff, and opening avenues for continuous feedback and troubleshooting are all potentially effective interventions to improve suicide screening rates within the veteran population.

This HPACT clinic initiative aimed to determine how a new screening process would be implemented while identifying potential areas for improvement. Surprisingly, 43% of patients who were screened had their screening performed outside of the HPACT clinic, most often in the inpatient setting at other WLAVAMC clinics or other VA systems. It is possible that due to the nature of the patient population that the HPACT clinic serves with intensive service needs, these patients have wider geographic and clinical location use than most clinic populations due to the transient nature of patients with housing insecurity. What is encouraging, however, is that through this systemwide initiative, there is an impetus to screen veterans, regardless of who performs the screening. This is particularly meaningful given that rates of depression screening may be as low as 4% among PCPs.¹⁵ During implementation, the QI team learned that nearly 18% of the empaneled HPACT patients were exempt from screening. The exempt patients do not have an active clinical reminder for depression screens. Instead, these patients are receiving mental health surveillance and specialty treatment, during which continuous monitoring and assessment for suicidal ideation and risk of suicide are performed. Additionally, an EHR-based factor that also may limit appropriate follow-up and contribute to missed opportunities is that secondary and tertiary screens do not populate until the EHR was refreshed after positive primary screens, which introduces human error in a process that could be automated. Both RNs and PCPs may occasionally miss secondary and tertiary screens due to this issue, which continues to be a barrier. Given the high risk HPACT clinic population, the QI team encouraged staff members to frequently screen patients for suicidal ideation regardless of clinical reminders. A consideration for the future would be to identify optimal frequency for screening and to continue to validate assessment methods.

Limitations

Due to the limited sample size, findings cannot be generalized to all VA sites. The QI team used retrospective, administrative data. Additionally, since this is a primary care clinic focused on a specialized population, this result may not be generalizable to all primary care settings, other primary care populations, or even other homeless primary care clinics, though it may establish a benchmark when other clinics internally examine their data and processes.

Conclusions

Improving screening protocols can lead to identification of at-risk individuals who would not have otherwise been identified.^16,17 As the US continues to grapple with mental health and suicide, efforts toward addressing this important issue among veterans remains a top priority.

Acknowledgments

Thank you to the VAGLAHS Center of Excellence in Primary Care Education faculty and trainees, the HPACT staff, and the VA Informatics and Computing Infrastructure (VINCI) for data support.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.

Despite the success of several US Department of Veterans Affairs (VA) initiatives in facilitating psychosocial functioning, rehabilitation, and re-entry among veterans experiencing homelessness and/or interactions with the criminal justice system (ie, justice-involved veterans), suicide risk among these veterans remains a significant public health concern. Rates of suicide among veterans experiencing homelessness are more than double that of veterans with no history of homelessness.¹ Similarly, justice-involved veterans experience myriad mental health concerns, including elevated rates of psychiatric symptoms, suicidal thoughts, and self-directed violence relative to those with no history of criminal justice involvement.²

In addition, a bidirectional relationship between criminal justice involvement and homelessness, often called the “institutional circuit,” is well established. Criminal justice involvement can directly result in difficulty finding housing.³ For example, veterans may have their lease agreement denied based solely on their history of criminogenic behavior. Moreover, criminal justice involvement can indirectly impact a veteran’s ability to maintain housing. Indeed, justice-involved veterans can experience difficulty attaining and sustaining employment, which in turn can result in financial difficulties, including inability to afford rental or mortgage payments.

Similarly, those at risk for or experiencing housing instability may resort to criminogenic behavior to survive in the context of limited psychosocial resources.^4-6 For instance, a veteran experiencing homelessness may seek refuge from inclement weather in a heated apartment stairwell and subsequently be charged with trespassing. Similarly, these veterans also may resort to theft to eat or pay bills. To this end, homelessness and justice involvement are likely a deleterious cycle that is difficult for the veteran to escape.

Unfortunately, the concurrent impact of housing insecurity and criminal justice involvement often serves to further exacerbate mental health sequelae, including suicide risk (Figure).⁷ In addition to precipitating frustration and helplessness among veterans who are navigating these stressors, these social determinants of health can engender a perception that the veteran is a burden to those in their support system. For example, these veterans may depend on friends or family to procure housing or transportation assistance for a job, medical appointments, and court hearings.