Federal Practitioner

To the Editor: Normally I would skip the editorial; however, the title “The Other Pandemic: Addiction” caught my eye (Fed Pract. 2020;37[10]:440-441). This will, of course, require me going in for eye care in the next couple of days, but my concerns are low. After all, the hook you used wasn’t that big.

Bravo! Your choice to focus on the effects of isolation was a masterful touch. I started skimming with the assumption that you would say something along the lines of ‘COVID bad, everybody depressed, blah, blah.’ But you cut into the abscess of the issue cleanly, exposing the core—isolation “amplifies negative thoughts, dysphoria, and fearful emotions.” A deadly combination for our patients and ourselves.

I have been a physician assistant in the US Army, and as a civilian at Brooke Army Medical Center and US Department of Veterans Affairs (VA) Puget Sound Health Care System. One thing I have seen throughout that time was the effects of isolation on the active duty enlisted young, and even more so on retired older warriors. Throughout the time of our military service, we transfer to many places and make a lot of friends, but more so, we lose track of them over time.

I have cared for many older warriors who cannot get something as simple as a colonoscopy because they do not have someone to drive them home after they have been sedated. Family and friends were scattered over the country, or the world. At the VA, many older warriors come not just for an appointment, but also as a time to socialize and ‘BS’ with those who understand them.

One goal I set for myself many years ago was to have the warrior laughing before they left my office. If I did that, I knew I had made a difference. Thank you for your editorial.

Anthony J Passaniti, PA, USA (ret) [email protected]

To the Editor: Normally I would skip the editorial; however, the title “The Other Pandemic: Addiction” caught my eye (Fed Pract. 2020;37[10]:440-441). This will, of course, require me going in for eye care in the next couple of days, but my concerns are low. After all, the hook you used wasn’t that big.

Bravo! Your choice to focus on the effects of isolation was a masterful touch. I started skimming with the assumption that you would say something along the lines of ‘COVID bad, everybody depressed, blah, blah.’ But you cut into the abscess of the issue cleanly, exposing the core—isolation “amplifies negative thoughts, dysphoria, and fearful emotions.” A deadly combination for our patients and ourselves.

I have been a physician assistant in the US Army, and as a civilian at Brooke Army Medical Center and US Department of Veterans Affairs (VA) Puget Sound Health Care System. One thing I have seen throughout that time was the effects of isolation on the active duty enlisted young, and even more so on retired older warriors. Throughout the time of our military service, we transfer to many places and make a lot of friends, but more so, we lose track of them over time.

I have cared for many older warriors who cannot get something as simple as a colonoscopy because they do not have someone to drive them home after they have been sedated. Family and friends were scattered over the country, or the world. At the VA, many older warriors come not just for an appointment, but also as a time to socialize and ‘BS’ with those who understand them.

One goal I set for myself many years ago was to have the warrior laughing before they left my office. If I did that, I knew I had made a difference. Thank you for your editorial.

Anthony J Passaniti, PA, USA (ret) [email protected]

To the Editor: Normally I would skip the editorial; however, the title “The Other Pandemic: Addiction” caught my eye (Fed Pract. 2020;37[10]:440-441). This will, of course, require me going in for eye care in the next couple of days, but my concerns are low. After all, the hook you used wasn’t that big.

Bravo! Your choice to focus on the effects of isolation was a masterful touch. I started skimming with the assumption that you would say something along the lines of ‘COVID bad, everybody depressed, blah, blah.’ But you cut into the abscess of the issue cleanly, exposing the core—isolation “amplifies negative thoughts, dysphoria, and fearful emotions.” A deadly combination for our patients and ourselves.

I have been a physician assistant in the US Army, and as a civilian at Brooke Army Medical Center and US Department of Veterans Affairs (VA) Puget Sound Health Care System. One thing I have seen throughout that time was the effects of isolation on the active duty enlisted young, and even more so on retired older warriors. Throughout the time of our military service, we transfer to many places and make a lot of friends, but more so, we lose track of them over time.

I have cared for many older warriors who cannot get something as simple as a colonoscopy because they do not have someone to drive them home after they have been sedated. Family and friends were scattered over the country, or the world. At the VA, many older warriors come not just for an appointment, but also as a time to socialize and ‘BS’ with those who understand them.

One goal I set for myself many years ago was to have the warrior laughing before they left my office. If I did that, I knew I had made a difference. Thank you for your editorial.

Anthony J Passaniti, PA, USA (ret) [email protected]

Case Presentation: A 45-year-old US Coast Guard veteran with a medical history of asthma and chronic back pain was referred to the VA Boston Healthcare System (VABHS) for evaluation of progressive, unexplained dyspnea. Two years prior to presentation, the patient was an avid outdoorsman and highly active. At the time of his initial primary care physician (PCP) evaluation he reported dyspnea on exertion, and symptoms consistent with an upper respiratory tract infection (URTI) and a recent tick bite with an associated rash. He was treated with intranasal fluticasone and a course of antibiotics. His URTI symptoms and rash improved; however the dyspnea persisted and progressed over the ensuing winter and he was referred for pulmonary function testing. Additional history included a 20 pack-year history of smoking (resolved 10 years prior to the first VABHS clinical encounter) and a family history of premature coronary artery disease (CAD) in his father and 2 paternal uncles. He lived in northern New England where he previously worked as a cemetery groundskeeper.

►Kristopher Clark, MD, Chief Medical Resident, VABHS and Boston University/Boston Medical Center: Dr. Goldstein, how do you approach a patient who presents with progressive dyspnea?

►Ronald Goldstein, MD, Chief of Pulmonary and Critical Care VABHS: The evaluation of dyspnea is a common problem for pulmonary physicians. The sensation of dyspnea may originate from a wide variety of etiologies that involve pulmonary and cardiovascular disorders, neuromuscular impairment, deconditioning, or psychological issues. It is important to characterize the temporal pattern, severity, progression, relation to exertion or other triggers, the smoking history, environmental and occupational exposures to pulmonary toxins, associated symptoms, and the history of pulmonary problems.¹

The physical examination may help to identify an airway or parenchymal disorder. Wheezing on chest examination would point to an obstructive defect and crackles to a possible restrictive problem, including pulmonary fibrosis. A cardiac examination should be performed to assess for evidence of heart failure, valvular heart disease, or the presence of loud P2 suggestive of pulmonary hypertension (PH). Laboratory studies, including complete blood counts are indicated.

A more complete pulmonary evaluation usually involves pulmonary function tests (PFTs), oximetry with exertion, and chest imaging. Additional cardiac testing might include electrocardiogram (ECG) and cardiac echocardiogram, followed by an exercise study, if needed. A B-natriuretic peptide determination could be considered if there is concern for congestive heart failure.²

►Dr. Clark: The initial physical examination was normal and laboratory tests were unrevealing. Given his history of asthma, he underwent spirometry testing (Table 1).

Dr. Goldstein, aside from unexplained dyspnea, what are other indications for spirometry and when should we consider ordering a full PFT, including lung volumes and diffusion capacity? Can you interpret this patient’s spirometry results?
 

►Dr. Goldstein: Spirometry is indicated to evaluate for a suspected obstructive defect. The test is usually performed with and without a bronchodilator to assess airway reactivity. A change in > 12% and > 200 mL suggests acute bronchodilator responsiveness. Periodic spirometry determinations are useful to assess the effect of medications or progression of disease. A reduction in forced vital capacity (FVC) may suggest a restrictive component. This possibility requires measure of lung volumes.

A full set of PFTs (ie, spirometry plus assessment of lung volumes and diffusion capacity) is required to evaluate the abnormalities associated with chronic obstructive pulmonary disease (COPD), interstitial diseases, vascular abnormalities (particularly PH), as well as for certain preoperative assessments. The single breath diffusing capacity for carbon monoxide is a measure of the overall capillary alveolar surface area of the lung. It is decreased in emphysema and interstitial disease as well as pulmonary vascular disorders. It would be particularly useful in this case as the spirometry studies were normal.

In this case, the normal FVC renders a significant restrictive disorder unlikely and his normal forced expiratory volume (FEV₁) and FEV₁/FVC make a significant obstructive disorder unlikely. He did not show any bronchodilator response; however, this finding does not exclude the presence of underlying asthma or reactive airway disease as patients often will not show a bronchodilator response at time of testing if they are not experiencing active bronchospasm or constriction. Further provocative testing with a methacholine challenge could be used to assess for reactive airway disease.

►Dr. Clark: The patient continued to have dyspnea when he returned to his PCP. Given his family history of premature CAD, an ECG was obtained that showed normal sinus rhythm at a rate of 70 beats per minute. A cardiology consult was placed, and he was referred for cardiac stress testing.

Dr. Maron, there are many forms of cardiac stress tests. In this case, the patient is referred for a stress test due his dyspnea. Does that symptom help you decide which test to order? How often does dyspnea present as an anginal equivalent in the absence of other cardiovascular symptoms or known cardiovascular disease?

►Bradley Maron, MD, Codirector, Pulmonary Vascular Disease Center, VABHS: In this case, stress testing should include a functional (ie, exercise) assessment if possible. Exercise capacity is a critical determinant of prognosis across the spectrum of cardiovascular disease and in a young person can be particularly informative on global health status. Furthermore, the chief complaint from this patient is dyspnea on exertion, and therefore, exercise testing is likely to be needed to reproduce or provoke the main symptom in this case. Estimates for dyspnea as a presenting symptom for ischemic heart disease vary but may be as high as 25%.³ It should be noted that cardiopulmonary exercise testing is useful for evaluating patients with unexplained dyspnea, as exercise hypoxemia, blunted decrease in V_D/V_T (ventilatory dead space/tidal volume), and evidence of a pulmonary mechanical limit to physical activity can inform the differential diagnosis.

►Dr. Clark: The patient underwent exercise treadmill testing and was able reach the target heart rate (> 85% age-predicted maximal heart rate) and achieve 11 metabolic equivalents. He had no chest pain or diagnostic ECG changes. The report made no mention of whether he experienced dyspnea during the test and was read as negative for exercise-induced ischemia.

He was seen by a cardiologist who noted an increased intensity S2 heart sound on examination without any other cardiopulmonary findings. It was noted that his symptoms occurred when tamping the ground or starting to walk up a hill but resolved with rest. It was also noted that his symptoms did not occur with gradual increased activity such as that performed during an exercise tolerance test. A 2-view chest X-ray was obtained and read as normal. Given the data from this evaluation thus far, the patient was told that his symptoms were most likely a result of his asthma exacerbated by dirt and dust exposure. Continued use of albuterol inhaler therapy was recommended, and no further diagnostic assessment was pursued.

Approximately 11 months later, the patient presented again to his PCP and reported progressive dyspnea. He had delayed seeking further care as he started to “feel like my symptoms were possibly in my head” given his prior negative workup. His symptoms had escalated drastically to the point where he felt short of breath with minimal exertion in addition to feeling sweaty, dizzy, fatigued, and having near-syncope when standing.

He was referred for a transthoracic echocardiogram (TTE) that revealed a left ventricular ejection fraction (LVEF) of 55 to 60% with diastolic relaxation abnormality and a normal-sized left atrium. The TTE also showed (qualitatively) a moderately dilated right ventricle with reduced systolic function, moderately severe tricuspid regurgitation, and severe elevation (> 60 mm Hg) in estimated right ventricular systolic pressure.

Dr. Maron, can you comment on how these findings may explain the patient’s symptoms? What differential diagnoses would you now consider?
 

►Dr. Maron: These echocardiography results exclude left ventricular systolic dysfunction or primary left-sided valvular disease at rest as a cause of the patient’s symptoms. In light of the patient’s prior normal stress test, high grade coronary disease in the absence of LV systolic dysfunction on echocardiography also seems unlikely. Estimated pulmonary artery systolic pressure > 60 mm Hg by echocardiography is highly suggestive of PH, but in and of itself does not diagnose PH nor inform pulmonary artery wedge pressure or pulmonary vascular resistance. Along with a direct measurement of pulmonary artery (PA) pressure, these data are needed to establish, classify, and prognosticate PH clinically.

►Dr. Clark: The patient was referred to a pulmonologist. His examination included bibasilar crackles and an enhanced P2 heart sound. A comprehensive pulmonary history was obtained, which noted his smoking history, possible asbestos exposure while serving in the Coast Guard, nighttime snoring without witnessed apnea events, and no personal or family history of thromboembolism or connective tissue disease.

Dr. Goldstein, is there anything in this patient’s history that could explain his symptoms and echocardiograph findings? Which tests would you order next?
 

►Dr. Goldstein: PH may be secondary to a wide variety of disorders including left heart disease (Group 2), advanced COPD, interstitial fibrosis, obstructive sleep apnea (OSA), or other lung diseases (Group 3), thromboembolic disorders (Group 4), and other systemic diseases such as sarcoidosis (Group 5). Group 1 is pulmonary arterial hypertension. (Table 2).

A right heart catheterization should be done to confirm the PA pressures estimated by echocardiogram. As to a cause, clinically he does not have heart failure. The limited smoking history and spirometry data do not support advanced COPD. He was noted to have crackles on physical examination suggesting an interstitial disorder. To assess the extent of interstitial disease, we would obtain a noncontrast computed tomography (CT) of the chest. The history of snoring suggesting the possibility of OSA indicating the need for overnight oximetry as significant nocturnal hypoxemia is a possible contributing cause to PH. A polysomnogram would be required to fully evaluate a sleep disturbance. The possible asbestos exposure is not likely a contributing factor as asbestosis requires significant exposure. We would obtain a ventilation/perfusion (V/Q) scan to rule out chronic thromboembolic disease. Targeted tests for causes of Group 5 disease should also be done.
 

►Dr. Clark: The impression from his pulmonologist was that the patient has severe PH, though the specific etiology was not yet known. Dr. Maron, can you review for us the pathophysiology behind PH and describe how the disease is classified?

►Dr. Maron: Elevated mean pulmonary artery pressure (> 20 mm Hg) diagnosed by supine right heart catheterization is the sine qua non of PH.⁴ However, this alone does not inform pathophysiology. As Dr. Goldstein noted, elevated PA pressure may be due to left heart disease, primary parenchymal lung disease/sleep-disordered breathing, in situ thrombotic remodeling of pulmonary arterioles following prior luminal pulmonary embolism, or in the setting of various specific predisposing conditions, such as sickle cell disease and sarcoidosis among others.⁵

Alternatively, pulmonary arterial hypertension (PAH) is suspected in patients with no identifiable cause of PH, pulmonary artery wedge pressure 15 mm Hg and pulmonary vascular resistance of 3.0 Wood units.⁶ Importantly, PAH is not synonymous with PH but is a circumspect PH disease subgroup. In turn, PAH may be idiopathic, hereditary, or associated with other select, predisposing disorders, namely systemic sclerosis. In PAH, the interplay between genetic and molecular factors results in effacement of distal pulmonary arterioles due to plexigenic, fibrotic, and/or concentric hypertrophic remodeling. Increased vascular resistance promotes early right ventricular dilation and impaired systolic function. As a result, patients with PAH are at particularly elevated risk for cor pulmonale.
 

►Dr. Clark: Overnight oximetry revealed baseline oxygen saturation of 94%, an oxygen nadir of 84% with a total of 7 minutes with oxygen < 90%. On a 6-minute walk test, the patient had a max heart rate of 116 and oxygen nadir of 93%. Chest CT with and without contrast showed no evidence of pulmonary emboli but noted mild emphysematous changes. A V/Q revealed no evidence of acute or chronic pulmonary thromboembolic disease. Coronary catheterization showed normal coronary anatomy without significant CAD. A right heart catheterization showed findings consistent with severe PH with normal left-sided filling pressures (Table 3).

The patient returned a normal antinuclear antibody, C-reactive protein, HIV, and liver function panel. Based on these findings, a presumptive diagnosis of group 1 PH (idiopathic PAH) was made. Given the severity of his right heart dysfunction, he was transferred to the cardiac care unit and initiated on epoprostenol.

Dr. Maron, can you review the different treatment options for idiopathic PAH and explain why epoprostenol was chosen for this patient?
 

►Dr. Maron: There are 14 US Food and Drug Administration-approved drug therapies for patients with PAH, which all target either nitric oxide signaling, endothelin receptors, or the prostacyclin pathway. In the current era, treatment-naïve patients with PAH are generally initiated on calcium channel antagonist therapy if there is evidence of vasoreactivity during right heart catheterization (following nitric oxide administration), dual therapy most often with an endothelin receptor antagonist and phosphodiesterase inhibitor, or parenteral prostacyclin therapy. Since < 5% of patients will demonstrate vasoreactivity, the decision at point of care in incident patients with PAH often focuses on dual oral therapy or initiation of parenteral prostacyclin therapy. In this case, the patient reported presyncope with minimal physical activity (eg, bending over or walking up stairs) and severely decreased functional status (ie, New York Heart Association Functional [NYHA] Class III – IV), and he had a cardiac index within the range of cardiogenic shock (< 2.0 L/min/m²). Collectively, this clinical profile is considered particularly high risk, therefore, a recommendation for parenteral continuous prostacyclin therapy was made.

► Dr. Clark: The patient tolerated epoprostenol and reported improvement in his symptoms. He had a tunneled line catheter placed for continuous epoprostenol infusion. He was discharged home and scheduled for outpatient follow-up in a PH clinic. At 4 months following discharge, he was reporting steady clinical and functional improvement as well as improvement in his dyspnea. A second therapy (oral phosphodiesterase type-V inhibitor) was initiated and tolerated well. Overall, he reported resolution of presyncope, NYHA Functional Class II symptoms, and the absence of important drug effects.

Case Presentation: A 45-year-old US Coast Guard veteran with a medical history of asthma and chronic back pain was referred to the VA Boston Healthcare System (VABHS) for evaluation of progressive, unexplained dyspnea. Two years prior to presentation, the patient was an avid outdoorsman and highly active. At the time of his initial primary care physician (PCP) evaluation he reported dyspnea on exertion, and symptoms consistent with an upper respiratory tract infection (URTI) and a recent tick bite with an associated rash. He was treated with intranasal fluticasone and a course of antibiotics. His URTI symptoms and rash improved; however the dyspnea persisted and progressed over the ensuing winter and he was referred for pulmonary function testing. Additional history included a 20 pack-year history of smoking (resolved 10 years prior to the first VABHS clinical encounter) and a family history of premature coronary artery disease (CAD) in his father and 2 paternal uncles. He lived in northern New England where he previously worked as a cemetery groundskeeper.

►Kristopher Clark, MD, Chief Medical Resident, VABHS and Boston University/Boston Medical Center: Dr. Goldstein, how do you approach a patient who presents with progressive dyspnea?

►Ronald Goldstein, MD, Chief of Pulmonary and Critical Care VABHS: The evaluation of dyspnea is a common problem for pulmonary physicians. The sensation of dyspnea may originate from a wide variety of etiologies that involve pulmonary and cardiovascular disorders, neuromuscular impairment, deconditioning, or psychological issues. It is important to characterize the temporal pattern, severity, progression, relation to exertion or other triggers, the smoking history, environmental and occupational exposures to pulmonary toxins, associated symptoms, and the history of pulmonary problems.¹

The physical examination may help to identify an airway or parenchymal disorder. Wheezing on chest examination would point to an obstructive defect and crackles to a possible restrictive problem, including pulmonary fibrosis. A cardiac examination should be performed to assess for evidence of heart failure, valvular heart disease, or the presence of loud P2 suggestive of pulmonary hypertension (PH). Laboratory studies, including complete blood counts are indicated.

A more complete pulmonary evaluation usually involves pulmonary function tests (PFTs), oximetry with exertion, and chest imaging. Additional cardiac testing might include electrocardiogram (ECG) and cardiac echocardiogram, followed by an exercise study, if needed. A B-natriuretic peptide determination could be considered if there is concern for congestive heart failure.²

►Dr. Clark: The initial physical examination was normal and laboratory tests were unrevealing. Given his history of asthma, he underwent spirometry testing (Table 1).

Dr. Goldstein, aside from unexplained dyspnea, what are other indications for spirometry and when should we consider ordering a full PFT, including lung volumes and diffusion capacity? Can you interpret this patient’s spirometry results?
 

►Dr. Goldstein: Spirometry is indicated to evaluate for a suspected obstructive defect. The test is usually performed with and without a bronchodilator to assess airway reactivity. A change in > 12% and > 200 mL suggests acute bronchodilator responsiveness. Periodic spirometry determinations are useful to assess the effect of medications or progression of disease. A reduction in forced vital capacity (FVC) may suggest a restrictive component. This possibility requires measure of lung volumes.

A full set of PFTs (ie, spirometry plus assessment of lung volumes and diffusion capacity) is required to evaluate the abnormalities associated with chronic obstructive pulmonary disease (COPD), interstitial diseases, vascular abnormalities (particularly PH), as well as for certain preoperative assessments. The single breath diffusing capacity for carbon monoxide is a measure of the overall capillary alveolar surface area of the lung. It is decreased in emphysema and interstitial disease as well as pulmonary vascular disorders. It would be particularly useful in this case as the spirometry studies were normal.

In this case, the normal FVC renders a significant restrictive disorder unlikely and his normal forced expiratory volume (FEV₁) and FEV₁/FVC make a significant obstructive disorder unlikely. He did not show any bronchodilator response; however, this finding does not exclude the presence of underlying asthma or reactive airway disease as patients often will not show a bronchodilator response at time of testing if they are not experiencing active bronchospasm or constriction. Further provocative testing with a methacholine challenge could be used to assess for reactive airway disease.

►Dr. Clark: The patient continued to have dyspnea when he returned to his PCP. Given his family history of premature CAD, an ECG was obtained that showed normal sinus rhythm at a rate of 70 beats per minute. A cardiology consult was placed, and he was referred for cardiac stress testing.

Dr. Maron, there are many forms of cardiac stress tests. In this case, the patient is referred for a stress test due his dyspnea. Does that symptom help you decide which test to order? How often does dyspnea present as an anginal equivalent in the absence of other cardiovascular symptoms or known cardiovascular disease?

►Bradley Maron, MD, Codirector, Pulmonary Vascular Disease Center, VABHS: In this case, stress testing should include a functional (ie, exercise) assessment if possible. Exercise capacity is a critical determinant of prognosis across the spectrum of cardiovascular disease and in a young person can be particularly informative on global health status. Furthermore, the chief complaint from this patient is dyspnea on exertion, and therefore, exercise testing is likely to be needed to reproduce or provoke the main symptom in this case. Estimates for dyspnea as a presenting symptom for ischemic heart disease vary but may be as high as 25%.³ It should be noted that cardiopulmonary exercise testing is useful for evaluating patients with unexplained dyspnea, as exercise hypoxemia, blunted decrease in V_D/V_T (ventilatory dead space/tidal volume), and evidence of a pulmonary mechanical limit to physical activity can inform the differential diagnosis.

►Dr. Clark: The patient underwent exercise treadmill testing and was able reach the target heart rate (> 85% age-predicted maximal heart rate) and achieve 11 metabolic equivalents. He had no chest pain or diagnostic ECG changes. The report made no mention of whether he experienced dyspnea during the test and was read as negative for exercise-induced ischemia.

He was seen by a cardiologist who noted an increased intensity S2 heart sound on examination without any other cardiopulmonary findings. It was noted that his symptoms occurred when tamping the ground or starting to walk up a hill but resolved with rest. It was also noted that his symptoms did not occur with gradual increased activity such as that performed during an exercise tolerance test. A 2-view chest X-ray was obtained and read as normal. Given the data from this evaluation thus far, the patient was told that his symptoms were most likely a result of his asthma exacerbated by dirt and dust exposure. Continued use of albuterol inhaler therapy was recommended, and no further diagnostic assessment was pursued.

Approximately 11 months later, the patient presented again to his PCP and reported progressive dyspnea. He had delayed seeking further care as he started to “feel like my symptoms were possibly in my head” given his prior negative workup. His symptoms had escalated drastically to the point where he felt short of breath with minimal exertion in addition to feeling sweaty, dizzy, fatigued, and having near-syncope when standing.

He was referred for a transthoracic echocardiogram (TTE) that revealed a left ventricular ejection fraction (LVEF) of 55 to 60% with diastolic relaxation abnormality and a normal-sized left atrium. The TTE also showed (qualitatively) a moderately dilated right ventricle with reduced systolic function, moderately severe tricuspid regurgitation, and severe elevation (> 60 mm Hg) in estimated right ventricular systolic pressure.

Dr. Maron, can you comment on how these findings may explain the patient’s symptoms? What differential diagnoses would you now consider?
 

►Dr. Maron: These echocardiography results exclude left ventricular systolic dysfunction or primary left-sided valvular disease at rest as a cause of the patient’s symptoms. In light of the patient’s prior normal stress test, high grade coronary disease in the absence of LV systolic dysfunction on echocardiography also seems unlikely. Estimated pulmonary artery systolic pressure > 60 mm Hg by echocardiography is highly suggestive of PH, but in and of itself does not diagnose PH nor inform pulmonary artery wedge pressure or pulmonary vascular resistance. Along with a direct measurement of pulmonary artery (PA) pressure, these data are needed to establish, classify, and prognosticate PH clinically.

►Dr. Clark: The patient was referred to a pulmonologist. His examination included bibasilar crackles and an enhanced P2 heart sound. A comprehensive pulmonary history was obtained, which noted his smoking history, possible asbestos exposure while serving in the Coast Guard, nighttime snoring without witnessed apnea events, and no personal or family history of thromboembolism or connective tissue disease.

Dr. Goldstein, is there anything in this patient’s history that could explain his symptoms and echocardiograph findings? Which tests would you order next?
 

►Dr. Goldstein: PH may be secondary to a wide variety of disorders including left heart disease (Group 2), advanced COPD, interstitial fibrosis, obstructive sleep apnea (OSA), or other lung diseases (Group 3), thromboembolic disorders (Group 4), and other systemic diseases such as sarcoidosis (Group 5). Group 1 is pulmonary arterial hypertension. (Table 2).

A right heart catheterization should be done to confirm the PA pressures estimated by echocardiogram. As to a cause, clinically he does not have heart failure. The limited smoking history and spirometry data do not support advanced COPD. He was noted to have crackles on physical examination suggesting an interstitial disorder. To assess the extent of interstitial disease, we would obtain a noncontrast computed tomography (CT) of the chest. The history of snoring suggesting the possibility of OSA indicating the need for overnight oximetry as significant nocturnal hypoxemia is a possible contributing cause to PH. A polysomnogram would be required to fully evaluate a sleep disturbance. The possible asbestos exposure is not likely a contributing factor as asbestosis requires significant exposure. We would obtain a ventilation/perfusion (V/Q) scan to rule out chronic thromboembolic disease. Targeted tests for causes of Group 5 disease should also be done.
 

►Dr. Clark: The impression from his pulmonologist was that the patient has severe PH, though the specific etiology was not yet known. Dr. Maron, can you review for us the pathophysiology behind PH and describe how the disease is classified?

►Dr. Maron: Elevated mean pulmonary artery pressure (> 20 mm Hg) diagnosed by supine right heart catheterization is the sine qua non of PH.⁴ However, this alone does not inform pathophysiology. As Dr. Goldstein noted, elevated PA pressure may be due to left heart disease, primary parenchymal lung disease/sleep-disordered breathing, in situ thrombotic remodeling of pulmonary arterioles following prior luminal pulmonary embolism, or in the setting of various specific predisposing conditions, such as sickle cell disease and sarcoidosis among others.⁵

Alternatively, pulmonary arterial hypertension (PAH) is suspected in patients with no identifiable cause of PH, pulmonary artery wedge pressure 15 mm Hg and pulmonary vascular resistance of 3.0 Wood units.⁶ Importantly, PAH is not synonymous with PH but is a circumspect PH disease subgroup. In turn, PAH may be idiopathic, hereditary, or associated with other select, predisposing disorders, namely systemic sclerosis. In PAH, the interplay between genetic and molecular factors results in effacement of distal pulmonary arterioles due to plexigenic, fibrotic, and/or concentric hypertrophic remodeling. Increased vascular resistance promotes early right ventricular dilation and impaired systolic function. As a result, patients with PAH are at particularly elevated risk for cor pulmonale.
 

►Dr. Clark: Overnight oximetry revealed baseline oxygen saturation of 94%, an oxygen nadir of 84% with a total of 7 minutes with oxygen < 90%. On a 6-minute walk test, the patient had a max heart rate of 116 and oxygen nadir of 93%. Chest CT with and without contrast showed no evidence of pulmonary emboli but noted mild emphysematous changes. A V/Q revealed no evidence of acute or chronic pulmonary thromboembolic disease. Coronary catheterization showed normal coronary anatomy without significant CAD. A right heart catheterization showed findings consistent with severe PH with normal left-sided filling pressures (Table 3).

The patient returned a normal antinuclear antibody, C-reactive protein, HIV, and liver function panel. Based on these findings, a presumptive diagnosis of group 1 PH (idiopathic PAH) was made. Given the severity of his right heart dysfunction, he was transferred to the cardiac care unit and initiated on epoprostenol.

Dr. Maron, can you review the different treatment options for idiopathic PAH and explain why epoprostenol was chosen for this patient?
 

►Dr. Maron: There are 14 US Food and Drug Administration-approved drug therapies for patients with PAH, which all target either nitric oxide signaling, endothelin receptors, or the prostacyclin pathway. In the current era, treatment-naïve patients with PAH are generally initiated on calcium channel antagonist therapy if there is evidence of vasoreactivity during right heart catheterization (following nitric oxide administration), dual therapy most often with an endothelin receptor antagonist and phosphodiesterase inhibitor, or parenteral prostacyclin therapy. Since < 5% of patients will demonstrate vasoreactivity, the decision at point of care in incident patients with PAH often focuses on dual oral therapy or initiation of parenteral prostacyclin therapy. In this case, the patient reported presyncope with minimal physical activity (eg, bending over or walking up stairs) and severely decreased functional status (ie, New York Heart Association Functional [NYHA] Class III – IV), and he had a cardiac index within the range of cardiogenic shock (< 2.0 L/min/m²). Collectively, this clinical profile is considered particularly high risk, therefore, a recommendation for parenteral continuous prostacyclin therapy was made.

► Dr. Clark: The patient tolerated epoprostenol and reported improvement in his symptoms. He had a tunneled line catheter placed for continuous epoprostenol infusion. He was discharged home and scheduled for outpatient follow-up in a PH clinic. At 4 months following discharge, he was reporting steady clinical and functional improvement as well as improvement in his dyspnea. A second therapy (oral phosphodiesterase type-V inhibitor) was initiated and tolerated well. Overall, he reported resolution of presyncope, NYHA Functional Class II symptoms, and the absence of important drug effects.

Case Presentation: A 45-year-old US Coast Guard veteran with a medical history of asthma and chronic back pain was referred to the VA Boston Healthcare System (VABHS) for evaluation of progressive, unexplained dyspnea. Two years prior to presentation, the patient was an avid outdoorsman and highly active. At the time of his initial primary care physician (PCP) evaluation he reported dyspnea on exertion, and symptoms consistent with an upper respiratory tract infection (URTI) and a recent tick bite with an associated rash. He was treated with intranasal fluticasone and a course of antibiotics. His URTI symptoms and rash improved; however the dyspnea persisted and progressed over the ensuing winter and he was referred for pulmonary function testing. Additional history included a 20 pack-year history of smoking (resolved 10 years prior to the first VABHS clinical encounter) and a family history of premature coronary artery disease (CAD) in his father and 2 paternal uncles. He lived in northern New England where he previously worked as a cemetery groundskeeper.

►Kristopher Clark, MD, Chief Medical Resident, VABHS and Boston University/Boston Medical Center: Dr. Goldstein, how do you approach a patient who presents with progressive dyspnea?

►Ronald Goldstein, MD, Chief of Pulmonary and Critical Care VABHS: The evaluation of dyspnea is a common problem for pulmonary physicians. The sensation of dyspnea may originate from a wide variety of etiologies that involve pulmonary and cardiovascular disorders, neuromuscular impairment, deconditioning, or psychological issues. It is important to characterize the temporal pattern, severity, progression, relation to exertion or other triggers, the smoking history, environmental and occupational exposures to pulmonary toxins, associated symptoms, and the history of pulmonary problems.¹

The physical examination may help to identify an airway or parenchymal disorder. Wheezing on chest examination would point to an obstructive defect and crackles to a possible restrictive problem, including pulmonary fibrosis. A cardiac examination should be performed to assess for evidence of heart failure, valvular heart disease, or the presence of loud P2 suggestive of pulmonary hypertension (PH). Laboratory studies, including complete blood counts are indicated.

A more complete pulmonary evaluation usually involves pulmonary function tests (PFTs), oximetry with exertion, and chest imaging. Additional cardiac testing might include electrocardiogram (ECG) and cardiac echocardiogram, followed by an exercise study, if needed. A B-natriuretic peptide determination could be considered if there is concern for congestive heart failure.²

►Dr. Clark: The initial physical examination was normal and laboratory tests were unrevealing. Given his history of asthma, he underwent spirometry testing (Table 1).

Dr. Goldstein, aside from unexplained dyspnea, what are other indications for spirometry and when should we consider ordering a full PFT, including lung volumes and diffusion capacity? Can you interpret this patient’s spirometry results?
 

►Dr. Goldstein: Spirometry is indicated to evaluate for a suspected obstructive defect. The test is usually performed with and without a bronchodilator to assess airway reactivity. A change in > 12% and > 200 mL suggests acute bronchodilator responsiveness. Periodic spirometry determinations are useful to assess the effect of medications or progression of disease. A reduction in forced vital capacity (FVC) may suggest a restrictive component. This possibility requires measure of lung volumes.

A full set of PFTs (ie, spirometry plus assessment of lung volumes and diffusion capacity) is required to evaluate the abnormalities associated with chronic obstructive pulmonary disease (COPD), interstitial diseases, vascular abnormalities (particularly PH), as well as for certain preoperative assessments. The single breath diffusing capacity for carbon monoxide is a measure of the overall capillary alveolar surface area of the lung. It is decreased in emphysema and interstitial disease as well as pulmonary vascular disorders. It would be particularly useful in this case as the spirometry studies were normal.

In this case, the normal FVC renders a significant restrictive disorder unlikely and his normal forced expiratory volume (FEV₁) and FEV₁/FVC make a significant obstructive disorder unlikely. He did not show any bronchodilator response; however, this finding does not exclude the presence of underlying asthma or reactive airway disease as patients often will not show a bronchodilator response at time of testing if they are not experiencing active bronchospasm or constriction. Further provocative testing with a methacholine challenge could be used to assess for reactive airway disease.

►Dr. Clark: The patient continued to have dyspnea when he returned to his PCP. Given his family history of premature CAD, an ECG was obtained that showed normal sinus rhythm at a rate of 70 beats per minute. A cardiology consult was placed, and he was referred for cardiac stress testing.

Dr. Maron, there are many forms of cardiac stress tests. In this case, the patient is referred for a stress test due his dyspnea. Does that symptom help you decide which test to order? How often does dyspnea present as an anginal equivalent in the absence of other cardiovascular symptoms or known cardiovascular disease?

►Bradley Maron, MD, Codirector, Pulmonary Vascular Disease Center, VABHS: In this case, stress testing should include a functional (ie, exercise) assessment if possible. Exercise capacity is a critical determinant of prognosis across the spectrum of cardiovascular disease and in a young person can be particularly informative on global health status. Furthermore, the chief complaint from this patient is dyspnea on exertion, and therefore, exercise testing is likely to be needed to reproduce or provoke the main symptom in this case. Estimates for dyspnea as a presenting symptom for ischemic heart disease vary but may be as high as 25%.³ It should be noted that cardiopulmonary exercise testing is useful for evaluating patients with unexplained dyspnea, as exercise hypoxemia, blunted decrease in V_D/V_T (ventilatory dead space/tidal volume), and evidence of a pulmonary mechanical limit to physical activity can inform the differential diagnosis.

►Dr. Clark: The patient underwent exercise treadmill testing and was able reach the target heart rate (> 85% age-predicted maximal heart rate) and achieve 11 metabolic equivalents. He had no chest pain or diagnostic ECG changes. The report made no mention of whether he experienced dyspnea during the test and was read as negative for exercise-induced ischemia.

He was seen by a cardiologist who noted an increased intensity S2 heart sound on examination without any other cardiopulmonary findings. It was noted that his symptoms occurred when tamping the ground or starting to walk up a hill but resolved with rest. It was also noted that his symptoms did not occur with gradual increased activity such as that performed during an exercise tolerance test. A 2-view chest X-ray was obtained and read as normal. Given the data from this evaluation thus far, the patient was told that his symptoms were most likely a result of his asthma exacerbated by dirt and dust exposure. Continued use of albuterol inhaler therapy was recommended, and no further diagnostic assessment was pursued.

Approximately 11 months later, the patient presented again to his PCP and reported progressive dyspnea. He had delayed seeking further care as he started to “feel like my symptoms were possibly in my head” given his prior negative workup. His symptoms had escalated drastically to the point where he felt short of breath with minimal exertion in addition to feeling sweaty, dizzy, fatigued, and having near-syncope when standing.

He was referred for a transthoracic echocardiogram (TTE) that revealed a left ventricular ejection fraction (LVEF) of 55 to 60% with diastolic relaxation abnormality and a normal-sized left atrium. The TTE also showed (qualitatively) a moderately dilated right ventricle with reduced systolic function, moderately severe tricuspid regurgitation, and severe elevation (> 60 mm Hg) in estimated right ventricular systolic pressure.

Dr. Maron, can you comment on how these findings may explain the patient’s symptoms? What differential diagnoses would you now consider?
 

►Dr. Maron: These echocardiography results exclude left ventricular systolic dysfunction or primary left-sided valvular disease at rest as a cause of the patient’s symptoms. In light of the patient’s prior normal stress test, high grade coronary disease in the absence of LV systolic dysfunction on echocardiography also seems unlikely. Estimated pulmonary artery systolic pressure > 60 mm Hg by echocardiography is highly suggestive of PH, but in and of itself does not diagnose PH nor inform pulmonary artery wedge pressure or pulmonary vascular resistance. Along with a direct measurement of pulmonary artery (PA) pressure, these data are needed to establish, classify, and prognosticate PH clinically.

►Dr. Clark: The patient was referred to a pulmonologist. His examination included bibasilar crackles and an enhanced P2 heart sound. A comprehensive pulmonary history was obtained, which noted his smoking history, possible asbestos exposure while serving in the Coast Guard, nighttime snoring without witnessed apnea events, and no personal or family history of thromboembolism or connective tissue disease.

Dr. Goldstein, is there anything in this patient’s history that could explain his symptoms and echocardiograph findings? Which tests would you order next?
 

►Dr. Goldstein: PH may be secondary to a wide variety of disorders including left heart disease (Group 2), advanced COPD, interstitial fibrosis, obstructive sleep apnea (OSA), or other lung diseases (Group 3), thromboembolic disorders (Group 4), and other systemic diseases such as sarcoidosis (Group 5). Group 1 is pulmonary arterial hypertension. (Table 2).

A right heart catheterization should be done to confirm the PA pressures estimated by echocardiogram. As to a cause, clinically he does not have heart failure. The limited smoking history and spirometry data do not support advanced COPD. He was noted to have crackles on physical examination suggesting an interstitial disorder. To assess the extent of interstitial disease, we would obtain a noncontrast computed tomography (CT) of the chest. The history of snoring suggesting the possibility of OSA indicating the need for overnight oximetry as significant nocturnal hypoxemia is a possible contributing cause to PH. A polysomnogram would be required to fully evaluate a sleep disturbance. The possible asbestos exposure is not likely a contributing factor as asbestosis requires significant exposure. We would obtain a ventilation/perfusion (V/Q) scan to rule out chronic thromboembolic disease. Targeted tests for causes of Group 5 disease should also be done.
 

►Dr. Clark: The impression from his pulmonologist was that the patient has severe PH, though the specific etiology was not yet known. Dr. Maron, can you review for us the pathophysiology behind PH and describe how the disease is classified?

►Dr. Maron: Elevated mean pulmonary artery pressure (> 20 mm Hg) diagnosed by supine right heart catheterization is the sine qua non of PH.⁴ However, this alone does not inform pathophysiology. As Dr. Goldstein noted, elevated PA pressure may be due to left heart disease, primary parenchymal lung disease/sleep-disordered breathing, in situ thrombotic remodeling of pulmonary arterioles following prior luminal pulmonary embolism, or in the setting of various specific predisposing conditions, such as sickle cell disease and sarcoidosis among others.⁵

Alternatively, pulmonary arterial hypertension (PAH) is suspected in patients with no identifiable cause of PH, pulmonary artery wedge pressure 15 mm Hg and pulmonary vascular resistance of 3.0 Wood units.⁶ Importantly, PAH is not synonymous with PH but is a circumspect PH disease subgroup. In turn, PAH may be idiopathic, hereditary, or associated with other select, predisposing disorders, namely systemic sclerosis. In PAH, the interplay between genetic and molecular factors results in effacement of distal pulmonary arterioles due to plexigenic, fibrotic, and/or concentric hypertrophic remodeling. Increased vascular resistance promotes early right ventricular dilation and impaired systolic function. As a result, patients with PAH are at particularly elevated risk for cor pulmonale.
 

►Dr. Clark: Overnight oximetry revealed baseline oxygen saturation of 94%, an oxygen nadir of 84% with a total of 7 minutes with oxygen < 90%. On a 6-minute walk test, the patient had a max heart rate of 116 and oxygen nadir of 93%. Chest CT with and without contrast showed no evidence of pulmonary emboli but noted mild emphysematous changes. A V/Q revealed no evidence of acute or chronic pulmonary thromboembolic disease. Coronary catheterization showed normal coronary anatomy without significant CAD. A right heart catheterization showed findings consistent with severe PH with normal left-sided filling pressures (Table 3).

The patient returned a normal antinuclear antibody, C-reactive protein, HIV, and liver function panel. Based on these findings, a presumptive diagnosis of group 1 PH (idiopathic PAH) was made. Given the severity of his right heart dysfunction, he was transferred to the cardiac care unit and initiated on epoprostenol.

Dr. Maron, can you review the different treatment options for idiopathic PAH and explain why epoprostenol was chosen for this patient?
 

►Dr. Maron: There are 14 US Food and Drug Administration-approved drug therapies for patients with PAH, which all target either nitric oxide signaling, endothelin receptors, or the prostacyclin pathway. In the current era, treatment-naïve patients with PAH are generally initiated on calcium channel antagonist therapy if there is evidence of vasoreactivity during right heart catheterization (following nitric oxide administration), dual therapy most often with an endothelin receptor antagonist and phosphodiesterase inhibitor, or parenteral prostacyclin therapy. Since < 5% of patients will demonstrate vasoreactivity, the decision at point of care in incident patients with PAH often focuses on dual oral therapy or initiation of parenteral prostacyclin therapy. In this case, the patient reported presyncope with minimal physical activity (eg, bending over or walking up stairs) and severely decreased functional status (ie, New York Heart Association Functional [NYHA] Class III – IV), and he had a cardiac index within the range of cardiogenic shock (< 2.0 L/min/m²). Collectively, this clinical profile is considered particularly high risk, therefore, a recommendation for parenteral continuous prostacyclin therapy was made.

► Dr. Clark: The patient tolerated epoprostenol and reported improvement in his symptoms. He had a tunneled line catheter placed for continuous epoprostenol infusion. He was discharged home and scheduled for outpatient follow-up in a PH clinic. At 4 months following discharge, he was reporting steady clinical and functional improvement as well as improvement in his dyspnea. A second therapy (oral phosphodiesterase type-V inhibitor) was initiated and tolerated well. Overall, he reported resolution of presyncope, NYHA Functional Class II symptoms, and the absence of important drug effects.

The novel coronavirus SARS-CoV-2 and resulting viral syndrome (COVID-19) was first reported in China during December 2019 and within weeks emerged in the US.¹ Since it is a rapidly evolving situation, clinicians must remain current on best practices—a challenging institutional responsibility. According to LitCovid, a curated literature hub for tracking scientific information on COVID-19, there are > 54,000 articles on the subject in PubMed. Among these include venous thromboembolism (VTE) prophylaxis guidance from 4 respected thrombosis organizations/societies and the US National Institutes of Health.^1-5

Observations

COVID-19 predisposes patients with and without a history of cardiovascular disease to thrombotic complications, occurring in either the venous or arterial circulation system.^2,6 Early observational studies suggest that thrombotic rates may be in excess of 20 to 30%; however, the use of prophylactic anticoagulation was inconsistent among studies that were rushed to publication.⁶

Autopsy data have demonstrated the presence of fibrin thrombi within distended small vessels and capillaries and extensive extracellular fibrin deposition.⁶ Investigators compared the characteristics of acute pulmonary embolism in 23 cases with COVID-19 but with no clinical signs of deep vein thrombosis with 100 controls without COVID-19.⁷ They observed that thrombotic lesions had a greater distribution in peripheral lung segments (ie, peripheral arteries) and were less extensive for those with COVID-19 vs without COVID-19 infection. Thus, experts currently hypothesize that COVID-19 has a distinct “pathomechanism.” As a unique phenotype, thrombotic events represent a combination of thromboembolic disease influenced by components of the Virchow triad (eg, acute illness and immobility) and in situ immunothrombosis, a local inflammatory response.^6,7

Well-established surgical and nonsurgical VTE thromboprophylaxis guidelines serve as the foundation for current COVID-19 thromboprophylaxis guidance.^8,9 Condition specific guidance is extrapolated from small, retrospective observational studies or based on expert opinion, representing levels 2 and 3 evidence, respectively.^1-5 Table 1 captures similarities and differences among COVID-19 VTE thromboprophylaxis recommendations which vary by time to publication and by society member expertise gained from practice in the field.

Conclusions

The COVID-19 pandemic has resulted in arguably the most challenging medical climate in the evidence-based medicine era. Until high-quality randomized controlled trials are published, the medical community is, in a sense, operating within a crucible of crisis having to navigate therapeutic policy with little certainty. This principle holds true for thromboprophylaxis in patients with COVID-19 despite the numerous advancements in this field over the past decade.

A review of societal guidance shows there is universal agreement with regards to supporting standard doses of pharmacologicalprophylaxis in acutely ill patients either when universally applied or guided by a RAM as well as the use of universal thromboprophylaxis in critically ill patients. All societies discourage the use of antiplatelet therapy for arterial thrombosis prevention and advocate for mechanical compression in patients with contraindications to pharmacologic anticoagulation. Beyond this, divergence between guidance statements begins to appear. For example, societies do not currently agree on the role and approach for extended pharmacologic prophylaxis postdischarge. The differences between societal guidance speaks to the degree of uncertainty among leading experts, which is considered to be the logical outworking of the current level of evidence. Regardless, these guidance documents should be considered the best resource currently available.

The medical community is fortunate to have robust societies that have published guidance on thromboprophylaxis in patients with COVID-19. The novelty of COVID-19 precludes these societal guidance publications from being based on high-quality evidence, but at the very least, they provide insight into how leading experts in the field of thrombosis and hemostasis are currently navigating the therapeutic landscape.

While this paper provides a summary of the current guidance, evidence is evolving at an unprecedented pace. Facilities and anticoagulation leads should be actively and frequently evaluating literature and guidance to ensure their practices and policies remain current.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Tennessee Valley Healthcare System in Nashville/Murfreesboro.

The novel coronavirus SARS-CoV-2 and resulting viral syndrome (COVID-19) was first reported in China during December 2019 and within weeks emerged in the US.¹ Since it is a rapidly evolving situation, clinicians must remain current on best practices—a challenging institutional responsibility. According to LitCovid, a curated literature hub for tracking scientific information on COVID-19, there are > 54,000 articles on the subject in PubMed. Among these include venous thromboembolism (VTE) prophylaxis guidance from 4 respected thrombosis organizations/societies and the US National Institutes of Health.^1-5

Observations

COVID-19 predisposes patients with and without a history of cardiovascular disease to thrombotic complications, occurring in either the venous or arterial circulation system.^2,6 Early observational studies suggest that thrombotic rates may be in excess of 20 to 30%; however, the use of prophylactic anticoagulation was inconsistent among studies that were rushed to publication.⁶

Autopsy data have demonstrated the presence of fibrin thrombi within distended small vessels and capillaries and extensive extracellular fibrin deposition.⁶ Investigators compared the characteristics of acute pulmonary embolism in 23 cases with COVID-19 but with no clinical signs of deep vein thrombosis with 100 controls without COVID-19.⁷ They observed that thrombotic lesions had a greater distribution in peripheral lung segments (ie, peripheral arteries) and were less extensive for those with COVID-19 vs without COVID-19 infection. Thus, experts currently hypothesize that COVID-19 has a distinct “pathomechanism.” As a unique phenotype, thrombotic events represent a combination of thromboembolic disease influenced by components of the Virchow triad (eg, acute illness and immobility) and in situ immunothrombosis, a local inflammatory response.^6,7

Well-established surgical and nonsurgical VTE thromboprophylaxis guidelines serve as the foundation for current COVID-19 thromboprophylaxis guidance.^8,9 Condition specific guidance is extrapolated from small, retrospective observational studies or based on expert opinion, representing levels 2 and 3 evidence, respectively.^1-5 Table 1 captures similarities and differences among COVID-19 VTE thromboprophylaxis recommendations which vary by time to publication and by society member expertise gained from practice in the field.

Conclusions

The COVID-19 pandemic has resulted in arguably the most challenging medical climate in the evidence-based medicine era. Until high-quality randomized controlled trials are published, the medical community is, in a sense, operating within a crucible of crisis having to navigate therapeutic policy with little certainty. This principle holds true for thromboprophylaxis in patients with COVID-19 despite the numerous advancements in this field over the past decade.

A review of societal guidance shows there is universal agreement with regards to supporting standard doses of pharmacologicalprophylaxis in acutely ill patients either when universally applied or guided by a RAM as well as the use of universal thromboprophylaxis in critically ill patients. All societies discourage the use of antiplatelet therapy for arterial thrombosis prevention and advocate for mechanical compression in patients with contraindications to pharmacologic anticoagulation. Beyond this, divergence between guidance statements begins to appear. For example, societies do not currently agree on the role and approach for extended pharmacologic prophylaxis postdischarge. The differences between societal guidance speaks to the degree of uncertainty among leading experts, which is considered to be the logical outworking of the current level of evidence. Regardless, these guidance documents should be considered the best resource currently available.

The medical community is fortunate to have robust societies that have published guidance on thromboprophylaxis in patients with COVID-19. The novelty of COVID-19 precludes these societal guidance publications from being based on high-quality evidence, but at the very least, they provide insight into how leading experts in the field of thrombosis and hemostasis are currently navigating the therapeutic landscape.

While this paper provides a summary of the current guidance, evidence is evolving at an unprecedented pace. Facilities and anticoagulation leads should be actively and frequently evaluating literature and guidance to ensure their practices and policies remain current.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Tennessee Valley Healthcare System in Nashville/Murfreesboro.

The novel coronavirus SARS-CoV-2 and resulting viral syndrome (COVID-19) was first reported in China during December 2019 and within weeks emerged in the US.¹ Since it is a rapidly evolving situation, clinicians must remain current on best practices—a challenging institutional responsibility. According to LitCovid, a curated literature hub for tracking scientific information on COVID-19, there are > 54,000 articles on the subject in PubMed. Among these include venous thromboembolism (VTE) prophylaxis guidance from 4 respected thrombosis organizations/societies and the US National Institutes of Health.^1-5

Observations

COVID-19 predisposes patients with and without a history of cardiovascular disease to thrombotic complications, occurring in either the venous or arterial circulation system.^2,6 Early observational studies suggest that thrombotic rates may be in excess of 20 to 30%; however, the use of prophylactic anticoagulation was inconsistent among studies that were rushed to publication.⁶

Autopsy data have demonstrated the presence of fibrin thrombi within distended small vessels and capillaries and extensive extracellular fibrin deposition.⁶ Investigators compared the characteristics of acute pulmonary embolism in 23 cases with COVID-19 but with no clinical signs of deep vein thrombosis with 100 controls without COVID-19.⁷ They observed that thrombotic lesions had a greater distribution in peripheral lung segments (ie, peripheral arteries) and were less extensive for those with COVID-19 vs without COVID-19 infection. Thus, experts currently hypothesize that COVID-19 has a distinct “pathomechanism.” As a unique phenotype, thrombotic events represent a combination of thromboembolic disease influenced by components of the Virchow triad (eg, acute illness and immobility) and in situ immunothrombosis, a local inflammatory response.^6,7

Well-established surgical and nonsurgical VTE thromboprophylaxis guidelines serve as the foundation for current COVID-19 thromboprophylaxis guidance.^8,9 Condition specific guidance is extrapolated from small, retrospective observational studies or based on expert opinion, representing levels 2 and 3 evidence, respectively.^1-5 Table 1 captures similarities and differences among COVID-19 VTE thromboprophylaxis recommendations which vary by time to publication and by society member expertise gained from practice in the field.

Conclusions

The COVID-19 pandemic has resulted in arguably the most challenging medical climate in the evidence-based medicine era. Until high-quality randomized controlled trials are published, the medical community is, in a sense, operating within a crucible of crisis having to navigate therapeutic policy with little certainty. This principle holds true for thromboprophylaxis in patients with COVID-19 despite the numerous advancements in this field over the past decade.

A review of societal guidance shows there is universal agreement with regards to supporting standard doses of pharmacologicalprophylaxis in acutely ill patients either when universally applied or guided by a RAM as well as the use of universal thromboprophylaxis in critically ill patients. All societies discourage the use of antiplatelet therapy for arterial thrombosis prevention and advocate for mechanical compression in patients with contraindications to pharmacologic anticoagulation. Beyond this, divergence between guidance statements begins to appear. For example, societies do not currently agree on the role and approach for extended pharmacologic prophylaxis postdischarge. The differences between societal guidance speaks to the degree of uncertainty among leading experts, which is considered to be the logical outworking of the current level of evidence. Regardless, these guidance documents should be considered the best resource currently available.

The medical community is fortunate to have robust societies that have published guidance on thromboprophylaxis in patients with COVID-19. The novelty of COVID-19 precludes these societal guidance publications from being based on high-quality evidence, but at the very least, they provide insight into how leading experts in the field of thrombosis and hemostasis are currently navigating the therapeutic landscape.

While this paper provides a summary of the current guidance, evidence is evolving at an unprecedented pace. Facilities and anticoagulation leads should be actively and frequently evaluating literature and guidance to ensure their practices and policies remain current.

Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VA Tennessee Valley Healthcare System in Nashville/Murfreesboro.

In the Veterans Health Administration (VHA), there are frequent e-mails and requests for employees to accept a detail or short-term assignment across a wide range of positions from administrative to executive leadership. These opportunities afford an employee and the service line valuable benefits and growth opportunities; however, there are reasons why some may be reluctant to pursue these opportunities. In this article, we discuss the barriers to applying for and accepting detail positions and the benefits for the employee and the service lines during periods of standard operations as well as during emergencies requiring alternative staffing strategies.

Details are short-term assignments used to fill a vacant position while hiring for the permanent position or to fill a short-term need (eg, during a pandemic). Details usually last 30 to 120 days, though they may be extended, depending on the position, the number of people willing to serve in the detailed role, and the time to select a candidate for the permanent position. Details can be created for any skill level or type of position to meet an identified need, but they are most often needed for supervisory or leadership roles.

The COVID-19 pandemic has shed light on the importance of individuals’ flexibility and adaptability both within and between roles. Many US Department of Veterans Affairs (VA) facilities stood up Incident Command structures to support the changes required to adapt to the needs created by the pandemic. Establishing an Incident Command means that people within the organization must take on new responsibilities, and in many cases, they are detailed to new positions that were not needed or prioritized before the pandemic.

Barriers

An employee may be reluctant to apply for or accept a detail because he or she has little to no experience; feels uncomfortable stepping into an unfamiliar role; is concerned about making a leap from a clinical to administrative role; has uncertainty whether the job is a good professional fit; dislikes the lack of a pay increase during the detail period even if the new role has more responsibility; and has concern that serving in the detail may make them ineligible to apply for the permanent position due to a perception of being preselected. Additionally, the employee may recognize the added stress on colleagues because the same amount of work must be completed.

Benefits

Although leaving a position for a period of months can be stressful, serving in a detail position provides significant opportunities for professional growth. An employee can gain knowledge and experience in an unfamiliar role before applying for or committing to a permanent position. Those serving in temporary details are often given more support as colleagues and supervisors understand that the role was accepted on short notice with little time to prepare. Other benefits include expanding professional contacts, gaining perspective on a different part of the VHA, and working on skills, such as flexibility, time management, and perseverance. By succeeding in a detail, employees build professional acumen. After taking on additional challenges they become more competitive for future jobs. The VHA Executive Candidate Development Program requires a 120-day detail, serving as either assistant or associate director, chief of staff, or associate director for patient care services/nurse executive as part of the program.¹

Temporarily leaving a service line to detail in a different service line has an impact on the home service because of the restrictions imposed. These restrictions guarantee that the employee can return to the original position at the end of a detail, thus providing a sense of job security; however, the home service line is down an employee.

Given these considerations, the following are key points to establish before undertaking the detail: (1) length of assignment; (2) once started, potential for the assignment to be extended; (3) will the employee be doing any of their prior job or just the new job or a blend of both; (4) possible changes in hours and site of work of the employee; (5) who will supervise the employee; (6) who will write the employee’s review; (7) training or skills needed prior to starting; (8) necessary paperwork; (9) how will the new assignment be communicated to others; (10) what happens if the detail ends sooner than planned; and (11) approval and support of all involved parties.

The employee’s home service may need a temporary plan to cover the employee’s workload, especially if the employee will be detailed to a different service line. The temporary plan may require creativity and flexibility and can be a way to trial the contingency plans for staffing the home service. One benefit to the home service is that the employee will have additional skills on returning that may benefit the home service, and the service will gain a potential leader.

When an employee goes to a different service, that service gains an employee who may bring a new perspective to help solve existing conflicts or problems. This can serve as a time to reset expectations or set new goals prior to the arrival of new leadership. If the detail is a good fit, then there is the chance that the employee may return in the future or refer others to it as a professional opportunity.

Conclusions

A detail can benefit the employee and the home and host services if planned in advance, and all parties support the process. A short-term leadership or administrative assignment can help an employee gain valuable experience for the future.

In the Veterans Health Administration (VHA), there are frequent e-mails and requests for employees to accept a detail or short-term assignment across a wide range of positions from administrative to executive leadership. These opportunities afford an employee and the service line valuable benefits and growth opportunities; however, there are reasons why some may be reluctant to pursue these opportunities. In this article, we discuss the barriers to applying for and accepting detail positions and the benefits for the employee and the service lines during periods of standard operations as well as during emergencies requiring alternative staffing strategies.

Details are short-term assignments used to fill a vacant position while hiring for the permanent position or to fill a short-term need (eg, during a pandemic). Details usually last 30 to 120 days, though they may be extended, depending on the position, the number of people willing to serve in the detailed role, and the time to select a candidate for the permanent position. Details can be created for any skill level or type of position to meet an identified need, but they are most often needed for supervisory or leadership roles.

The COVID-19 pandemic has shed light on the importance of individuals’ flexibility and adaptability both within and between roles. Many US Department of Veterans Affairs (VA) facilities stood up Incident Command structures to support the changes required to adapt to the needs created by the pandemic. Establishing an Incident Command means that people within the organization must take on new responsibilities, and in many cases, they are detailed to new positions that were not needed or prioritized before the pandemic.

Barriers

An employee may be reluctant to apply for or accept a detail because he or she has little to no experience; feels uncomfortable stepping into an unfamiliar role; is concerned about making a leap from a clinical to administrative role; has uncertainty whether the job is a good professional fit; dislikes the lack of a pay increase during the detail period even if the new role has more responsibility; and has concern that serving in the detail may make them ineligible to apply for the permanent position due to a perception of being preselected. Additionally, the employee may recognize the added stress on colleagues because the same amount of work must be completed.

Benefits

Although leaving a position for a period of months can be stressful, serving in a detail position provides significant opportunities for professional growth. An employee can gain knowledge and experience in an unfamiliar role before applying for or committing to a permanent position. Those serving in temporary details are often given more support as colleagues and supervisors understand that the role was accepted on short notice with little time to prepare. Other benefits include expanding professional contacts, gaining perspective on a different part of the VHA, and working on skills, such as flexibility, time management, and perseverance. By succeeding in a detail, employees build professional acumen. After taking on additional challenges they become more competitive for future jobs. The VHA Executive Candidate Development Program requires a 120-day detail, serving as either assistant or associate director, chief of staff, or associate director for patient care services/nurse executive as part of the program.¹

Temporarily leaving a service line to detail in a different service line has an impact on the home service because of the restrictions imposed. These restrictions guarantee that the employee can return to the original position at the end of a detail, thus providing a sense of job security; however, the home service line is down an employee.

Given these considerations, the following are key points to establish before undertaking the detail: (1) length of assignment; (2) once started, potential for the assignment to be extended; (3) will the employee be doing any of their prior job or just the new job or a blend of both; (4) possible changes in hours and site of work of the employee; (5) who will supervise the employee; (6) who will write the employee’s review; (7) training or skills needed prior to starting; (8) necessary paperwork; (9) how will the new assignment be communicated to others; (10) what happens if the detail ends sooner than planned; and (11) approval and support of all involved parties.

The employee’s home service may need a temporary plan to cover the employee’s workload, especially if the employee will be detailed to a different service line. The temporary plan may require creativity and flexibility and can be a way to trial the contingency plans for staffing the home service. One benefit to the home service is that the employee will have additional skills on returning that may benefit the home service, and the service will gain a potential leader.

When an employee goes to a different service, that service gains an employee who may bring a new perspective to help solve existing conflicts or problems. This can serve as a time to reset expectations or set new goals prior to the arrival of new leadership. If the detail is a good fit, then there is the chance that the employee may return in the future or refer others to it as a professional opportunity.

Conclusions

A detail can benefit the employee and the home and host services if planned in advance, and all parties support the process. A short-term leadership or administrative assignment can help an employee gain valuable experience for the future.

In the Veterans Health Administration (VHA), there are frequent e-mails and requests for employees to accept a detail or short-term assignment across a wide range of positions from administrative to executive leadership. These opportunities afford an employee and the service line valuable benefits and growth opportunities; however, there are reasons why some may be reluctant to pursue these opportunities. In this article, we discuss the barriers to applying for and accepting detail positions and the benefits for the employee and the service lines during periods of standard operations as well as during emergencies requiring alternative staffing strategies.

Details are short-term assignments used to fill a vacant position while hiring for the permanent position or to fill a short-term need (eg, during a pandemic). Details usually last 30 to 120 days, though they may be extended, depending on the position, the number of people willing to serve in the detailed role, and the time to select a candidate for the permanent position. Details can be created for any skill level or type of position to meet an identified need, but they are most often needed for supervisory or leadership roles.

The COVID-19 pandemic has shed light on the importance of individuals’ flexibility and adaptability both within and between roles. Many US Department of Veterans Affairs (VA) facilities stood up Incident Command structures to support the changes required to adapt to the needs created by the pandemic. Establishing an Incident Command means that people within the organization must take on new responsibilities, and in many cases, they are detailed to new positions that were not needed or prioritized before the pandemic.

Barriers

An employee may be reluctant to apply for or accept a detail because he or she has little to no experience; feels uncomfortable stepping into an unfamiliar role; is concerned about making a leap from a clinical to administrative role; has uncertainty whether the job is a good professional fit; dislikes the lack of a pay increase during the detail period even if the new role has more responsibility; and has concern that serving in the detail may make them ineligible to apply for the permanent position due to a perception of being preselected. Additionally, the employee may recognize the added stress on colleagues because the same amount of work must be completed.

Benefits

Although leaving a position for a period of months can be stressful, serving in a detail position provides significant opportunities for professional growth. An employee can gain knowledge and experience in an unfamiliar role before applying for or committing to a permanent position. Those serving in temporary details are often given more support as colleagues and supervisors understand that the role was accepted on short notice with little time to prepare. Other benefits include expanding professional contacts, gaining perspective on a different part of the VHA, and working on skills, such as flexibility, time management, and perseverance. By succeeding in a detail, employees build professional acumen. After taking on additional challenges they become more competitive for future jobs. The VHA Executive Candidate Development Program requires a 120-day detail, serving as either assistant or associate director, chief of staff, or associate director for patient care services/nurse executive as part of the program.¹

Temporarily leaving a service line to detail in a different service line has an impact on the home service because of the restrictions imposed. These restrictions guarantee that the employee can return to the original position at the end of a detail, thus providing a sense of job security; however, the home service line is down an employee.

Given these considerations, the following are key points to establish before undertaking the detail: (1) length of assignment; (2) once started, potential for the assignment to be extended; (3) will the employee be doing any of their prior job or just the new job or a blend of both; (4) possible changes in hours and site of work of the employee; (5) who will supervise the employee; (6) who will write the employee’s review; (7) training or skills needed prior to starting; (8) necessary paperwork; (9) how will the new assignment be communicated to others; (10) what happens if the detail ends sooner than planned; and (11) approval and support of all involved parties.

The employee’s home service may need a temporary plan to cover the employee’s workload, especially if the employee will be detailed to a different service line. The temporary plan may require creativity and flexibility and can be a way to trial the contingency plans for staffing the home service. One benefit to the home service is that the employee will have additional skills on returning that may benefit the home service, and the service will gain a potential leader.

When an employee goes to a different service, that service gains an employee who may bring a new perspective to help solve existing conflicts or problems. This can serve as a time to reset expectations or set new goals prior to the arrival of new leadership. If the detail is a good fit, then there is the chance that the employee may return in the future or refer others to it as a professional opportunity.

Conclusions

A detail can benefit the employee and the home and host services if planned in advance, and all parties support the process. A short-term leadership or administrative assignment can help an employee gain valuable experience for the future.

Since 2008, suicide has ranked as the tenth leading cause of death for all ages in the US, with rates of suicide continuing to rise.^1-3 Suicide is even more urgent to address in veteran populations. The age- and sex-adjusted suicide rate in 2017 was more than 1.5 times greater for veterans than it was for nonveteran adults.² Of importance, rates of suicide are increasing at a faster rate in veterans who are not connected to Veterans Health Administration (VHA) care.^4,5 These at-risk veterans include individuals who are eligible for VHA care yet have not had a VHA appointment within the year before death; veterans who may be ineligible to receive VHA care due to complex rules set by legislation; and veterans who are eligible but not enrolled in VHA care. Notably, between 2005 and 2016, the number of veterans not enrolled in VHA care rose more quickly than did the number of veterans enrolled in VHA care.^5,6 Thus, to impact the high veteran suicide rates, an emergent challenge for VHA is to prevent suicide among unenrolled veterans and veterans receiving community care, while continuing to increase access to mental health services for veterans enrolled in VHA health care.

In response to the high rates of veteran suicide deaths, the US Department of Veterans Affairs (VA) has developed a broad, multicomponent suicide prevention program that is unparalleled in private US health care systems.^4,7 Suicide prevention efforts are led and implemented by both the VHA National Center for Patient Safety and the VHA Office of Mental Health and Suicide Prevention. Program components are numerous and multifaceted, falling within the broad promotion and prevention strategies outlined by the National Academy of Medicine (NAM).^1,8-11 The NAM continuum of prevention model encompassing multiple strategies is also referred to as the Universal, Selective, Indicated (USI) Model.^7,8,10 The VHA suicide prevention program contains a wide spread of program components, making it both comprehensive and innovative (Table 1).

Although significant momentum and progress has been made within the VHA, policy set by legislation has historically limited access to VHA health care services to VHA-eligible veterans. This is particularly concerning given the rising suicide rates among veterans not engaged in VHA care.² Adding to this complexity, recent legislation has increased veterans’ access to non-VHA health care, in addition to their existing access through Medicare, Medicaid, and other health care programs.^12-14 Best practices for suicide prevention are not often implemented in the private sector; thus, these systems are ill prepared to adequately meet the suicide prevention care needs of veterans.^4,15-18 Furthermore, VHA and non-VHA services generally are not well coordinated, and private sector health care providers (HCPs) are not required to complete a commensurate level of suicide prevention training as are VHA HCPs.^16-18 Most non-VHA HCPs do not receive military cultural competence training.¹⁹ These issues create a significant gap in suicide prevention services and may contribute to the increases in suicide rates in veterans who do not receive VHA care. Thus, changes in policy to increase access through private sector care may have paradoxical effects on veteran suicide deaths. To impact the veteran suicide rate, VHA must develop and disseminate best practices for veterans who use non-VHA services.

A Roadmap to Suicide Prevention

There is significant momentum at the federal level regarding this issue. The President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (Executive Order 13,861) directs the VHA to work closely with community organizations to improve veteran suicide prevention.²⁰ The VHA and partners, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), are bridging this gap with collaborative efforts that increase suicide prevention resources for veterans living in the community through programs such as the Governor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families. These programs intend to empower communities to develop statewide, strategic action plans to prevent veteran suicide.^7,21-24

In addition to partnerships, VHA has built other aspects of outreach and intervention into its programming. A key VHA initiative is to “know all veterans” by committing to identifying and reaching out to all veterans who may be at risk for suicide.²² The VHA has committed to offering “emergency stabilization care for former service members who present at the facility with an emergent mental health need” regardless of eligibility.²⁵ The intent is to provide temporary emergent mental health care to veterans who are otherwise ineligible for care, such as those who were discharged under other-than-honorable conditions while the VHA determines eligibility status.²⁶ However, veterans must meet certain criteria, and there is a limit on services.

Although services are being expanded to reach veterans who do not access VHA health care, how to best implement these new directives with regard to suicide prevention is unclear. Strategic development and innovations to expand suicide prevention care to veterans outside the current reach of VHA are desperately needed.

Program Overview 

VHA Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), funded by the VHA National Center for Patient Safety, aims to help fill the gap in community-based suicide prevention for veterans. PSCI-SPC is located within the VHA Rocky Mountain Mental Illness Research, Education, and Clinical Center in Aurora, Colorado. The overarching mission of PSCI-SPC is to develop, implement, and evaluate practical solutions to reduce suicide among veterans not receiving VHA care. PSCI-SPC serves as a national clinical innovation and dissemination center for best practices in suicide prevention for organizations that serve veterans who receive care in the community. PSCI-SPC creates products to support dissemination of these practices to other VAMCs and works to ensure these programs are sustainable. PSCI-SPC focuses on 3 primary objectives. All PSCI-SPC projects are currently underway.

Objective 1: Growing a Community Learning Collaborative

Acknowledging that nearly two-thirds of veterans who die by suicide do not use VHA services, PSCI-SPC aims to reduce suicide among all veterans by expanding the reach of best practices for suicide prevention to veterans who receive myriad services in the community.²⁷ Community organizations are defined here as organizations that may in some way serve, interact with, or work with veterans, and/or employ veterans. Examples include non-VHA health care systems, public services such as police and fire departments, nonprofit organizations, mental health clinics, and veterans’ courts. As veterans increasingly seek health care and other services within their communities, the success of suicide prevention will be influenced by the capability of non-VHA public and private organizations. Objective 1, therefore, seeks to develop a VHA-community collaborative that can be leveraged to improve systems of suicide prevention.

Current programs in the VHA have focused on implementation of suicide prevention awareness and prevention education campaigns instead of grassroots partnerships that are intended to be sustainable. Additionally, these programs typically lack the capacity and systems to sustain numerous meaningful community partnerships. Traditionally, community organizations have been hesitant to partner with government agencies, such as the VHA, due to histories of institutional mistrust and bureaucracy.²⁸

The PSCI-SPC model for developing a VHA-community collaborative partnership draws from the tradition of community-based participatory research. The best community-based participatory research practices are to build on strengths and resources within the local community; develop collaborative, equitable partnerships that involve an empowering and power-sharing process; foster colearning, heuristics, and capacity building among partners; and focus on systems development using an iterative process. These practices also are consistent with the literature on learning collaboratives.^29-31

The premise for a learning collaborative is to bridge the gap between knowledge and practice in health care.³¹ Figure 1 depicts how this collaborative was developed, and how it supports Objectives 2 and 3. To achieve Objective 1, we developed a VHA-learning collaborative of 13 influential community partners in the Denver and Colorado Springs region of Colorado. The VHA team consists of a learning collaborative leader, a program manager, and a program support assistant. The principal investigator attends and contributes to all meetings. Learning collaborative partners include a university psychology clinic that focuses on veterans’ care, 3 veterans service organizations, a mental health private practice, a university school of nursing, a community mental health center, veterans’ courts, and 5 city departments.

Objective 2: Implementation Toolkit

The second PSCI-SPC objective is to develop a toolkit for the implementation of best practices within a VHA-community suicide prevention learning collaborative. Lessons from the development of a successful suicide prevention learning collaborative will be shared through an online guide that other VHA facilities can use to support similar collaborative efforts within their communities. The toolkit will be disseminated across the VHA to assist suicide prevention coordinators and other staff in developing a suicide prevention learning collaborative at their facilities.

PSCI-SPC uses the Zero Suicide framework and the VA/US Department of Defense (DoD) Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide as models for preventing suicide in veterans not enrolled in VHA care.^11,32 This implementation toolkit focuses on how to implement suicide prevention best practices into organizations that serve veterans. This toolkit differs from clinical practice guidelines in that it focuses on implementation strategies to promote success and effectively address challenges.

In order to provide a menu of available options for the learning collaborative and resulting toolkit, PSCI-SPC uses a logic model to compare the components of the VHA suicide prevention program, as well as other similar veteran and military suicide prevention programs.^{7,12,14,21,33,34} These programs are categorized into 2 types of prevention frameworks, the USI model as described above, and the SAMHSA Strategic Prevention Framework (Table 2).³⁵ The SAMHSA framework was designed to promote mental health and prevent substance abuse, yet the derived classification is also applicable to suicide prevention programs.³⁵ The results of the logic model comparison form the basis of the best practice interventions for the learning collaborative and initial toolkit. In addition to the best practice interventions, the toolkit consists of documents describing how to develop a veteran suicide prevention learning collaborative, as well as tools for learning collaborative members. Current tool development includes workbooks to guide collaborative members through the implementation process, guides for community organizations in implementing suicide prevention screening and risk assessment, a standard operating procedure for suicide prevention in a veterans court, and peer support training for veteran suicide prevention.

Objective 3: High-Risk Veterans Not Receiving VHA Care

Although veterans not receiving VHA care account for a number of veteran deaths by suicide, we are not aware of any current VHA programs that provide temporary psychotherapy and intensive case management to at-risk veterans ineligible for VHA care who are in need of immediate care while an appropriate permanent community placement is identified. In the current system, veterans in the community can present to VHA suicide prevention services through several different systems, including referrals to VHA and the Veterans Crisis Line (VCL). However, a portion of VCL calls are from veterans whose VHA eligibility is unknown or who are ineligible for services. If veterans are at imminent risk for suicide, emergency care is coordinated for them. However, if veterans are not at imminent suicide risk they are referred to the local suicide prevention coordinator and instructed to independently work toward determining their VHA eligibility.

It is currently unknown how many veterans follow through with these instructions. Nonetheless, if veterans are deemed eligible, they may present to VHA to obtain a same-day appointment. If not eligible, a suicide prevention coordinator may give them the phone number of a community referral. However, this practice is not standardized across VA medical centers, and the provided resources are up to the suicide prevention coordinator to research. Additionally, when a VHA suicide prevention coordinator leaves the position, knowledge of these community resources and rapport with community HCPs are often lost, leaving the next coordinator to develop these again, which reduces the efficiency and effectiveness of limited resources. It is also unknown how many veterans complete this contact and receive evidence-based treatment following referral. This is a complex system to navigate, particularly when at risk for suicide and in need of immediate but not emergency services.

Suicide prevention in such circumstances may be improved by adapting current suicide prevention practices, including evidence-based interventions, and the new VHA intensive case management program,^11,36 within a Zero Suicide framework. PSCI-SPC has developed a brief intervention to transition ineligible veterans to permanent community treatment and provide them with additional resources to meet their varied needs. The brief 1 to 3 session intervention combines practices from brief cognitive behavioral therapy (BCBT) for suicide prevention, crisis response planning (CRP), and intensive case management within a Zero Suicide framework. Both the 2019 VA/DoD suicide prevention clinical practice guidelines and Zero Suicide recommend using cognitive behavioral therapy (CBT)-based interventions for suicide prevention.^11,32 These interventions are packaged into a single intervention delivered by a PSCI-SPC therapist, typically a licensed clinical social worker, a licensed clinical psychologist, or an unlicensed psychologist under the supervision of a licensed clinical psychologist.

BCBT is one type of CBT that has shown initial efficacy in reducing suicide attempts.³⁷ BCBT reduces the risk for suicide attempts both at the conclusion of treatment and at 24-month follow-up.³⁷ BCBT is boiled down to its most essential components so it can be delivered in a distilled format. An essential element of BCBT that will remain is the CRP. A CRP^11,37,38 entails collaboratively identifying effective, appropriate coping strategies and specific individuals to contact during a crisis. CRPs demonstrated efficacy as a stand-alone intervention to existing suicide prevention methods in a randomized clinical trial, such that individuals who received CRP had faster reductions in suicidal ideation and were 76% less likely to make a suicide attempt during the 6-month follow-up period.³⁹ These results demonstrate that use of a CRP is connected to a decrease in suicidal behavior among suicidal patients.

The VHA has developed and is piloting a new initiative focused on restructuring its intensive case management services. RACETIME to Integrated Care (eg, Risk stratification, Assessment of complexity, Coordinator of lead assignment, Evaluate whole health needs, Trusting partnerships, Integrate care, Monitor progress, Experience of the veteran and employee) is a framework that assists VHA case managers in transitioning from a traditional case management mind-set to a more integrated and holistic method of care.³⁶ RACETIME intensive case management practices will be incorporated into the intervention. However, RACETIME focuses on case management internally to the VHA. A modification for this treatment will be to focus on intensive case management from a mental health perspective and connecting to external community resources. Community referrals are mapped within a structured process and stored on a shared drive. This improves continuity between suicide prevention coordinators when they leave for a new position.

This intervention is conducted within a Zero Suicide framework. Pertinent to PSCI-SPC innovation to enhance care for non-VHA veterans is the care transitions element within the Zero Suicide framework, which has developed comprehensive suicide prevention guidance, including a pathway to care.³² This pathway refers a process to conduct follow-up supportive contacts that are tracked and recorded.

The PSCI-SPC pilot program incorporates the elements of CRP and brief CBT within a Zero Suicide framework. The PSCI-SPC team is developing and testing a protocol for providing brief treatment and community referrals to ineligible veterans that integrates these programming elements (Figure 2). A PSCI-SPC social worker will coordinate with the eligibility office to determine VHA eligibility. Ineligible veterans are referred to community partners and nonenrolled, eligible veterans are linked to VHA HCPs if they desire. These transitions will be coordinated, closely monitored, and verified. The PSCI-SPC team receives referrals from the VCL and other VHA programs that are in contact with ineligible veterans. Other program eligibility criteria include meeting 1 of 3 criteria: (1) a lifetime suicide attempt; (2) suicidal ideation in the past 6 months; or (3) a current mental health disorder. At the outset of the program, it is explained that the purpose of the intervention is to provide short-term, transitional services to assist the veteran in attaining a permanent mental health placement.

Discussion

Improving suicide prevention for veterans who receive non-VHA health care is essential to significantly reduce veteran suicide rates. For the past decade, VHA suicide prevention initiatives have largely focused on veterans eligible for care, although the fastest increase in veteran suicide rates has occurred among veterans not connected to VHA services. Currently, if a veteran is deemed ineligible for care, it is up to the veteran to find other health care services in his or her community. There is not always a clear next step for the veteran to take, nor clear guidance provided to the VHA registration staff to assist with this care transition. This is particularly concerning for veterans at high risk for suicide as this could further thwart the veteran’s sense of belongingness and increase perceived burdensomeness, both suicide risk factors, and discourage them from attaining help.⁴⁰ Overall, while the VHA has successfully implemented diverse suicide prevention initiatives and services, the need for continued system improvement focused on non-VHA veterans remains. PSCI-SPC was developed for this purpose.

By creating a collaborative that will connect VHA and community organizations, there will be better utilization of resources and more appropriate referrals throughout systems that interact with veterans. Sharing suicide prevention best practices between VHA and community partners is expected to increase access to mental health treatment to all veterans. Finally, by allowing best practices for suicide prevention in the VHA to serve as a guide in the development of best practices for suicide prevention between the VHA and the local health and behavioral health care community, PSCI-SPC will create a new suicide prevention intervention for veterans with mental health needs. Through these initiatives, PSCI-SPC will support providers’ and concerned citizens’ efforts to ensure that fewer veterans fall through the cracks of disjointed systems and will promote healthier communities where, regardless of VHA enrollment status, veterans receive suicide prevention care.

Conclusions

PSCI-SPC is a novel center for the innovation and dissemination of the nation’s best practices in suicide prevention for veterans who are ineligible for or otherwise not engaged in VHA services and who turn to their community for health care. PSCI-SPC not only seeks to create, develop, and measure various solutions to reduce suicide among veterans who receive non-VHA care, but also seeks to facilitate the overall quality of existing practices for suicide prevention and care coordination for enrolled veterans who use community resources. By bridging the gap between the VHA, civilian health care systems, and other community partners striving to prevent veteran suicides, we can create better access to care and a more seamless path of communication among these important entities that impact the lives of our veterans daily

Since 2008, suicide has ranked as the tenth leading cause of death for all ages in the US, with rates of suicide continuing to rise.^1-3 Suicide is even more urgent to address in veteran populations. The age- and sex-adjusted suicide rate in 2017 was more than 1.5 times greater for veterans than it was for nonveteran adults.² Of importance, rates of suicide are increasing at a faster rate in veterans who are not connected to Veterans Health Administration (VHA) care.^4,5 These at-risk veterans include individuals who are eligible for VHA care yet have not had a VHA appointment within the year before death; veterans who may be ineligible to receive VHA care due to complex rules set by legislation; and veterans who are eligible but not enrolled in VHA care. Notably, between 2005 and 2016, the number of veterans not enrolled in VHA care rose more quickly than did the number of veterans enrolled in VHA care.^5,6 Thus, to impact the high veteran suicide rates, an emergent challenge for VHA is to prevent suicide among unenrolled veterans and veterans receiving community care, while continuing to increase access to mental health services for veterans enrolled in VHA health care.

In response to the high rates of veteran suicide deaths, the US Department of Veterans Affairs (VA) has developed a broad, multicomponent suicide prevention program that is unparalleled in private US health care systems.^4,7 Suicide prevention efforts are led and implemented by both the VHA National Center for Patient Safety and the VHA Office of Mental Health and Suicide Prevention. Program components are numerous and multifaceted, falling within the broad promotion and prevention strategies outlined by the National Academy of Medicine (NAM).^1,8-11 The NAM continuum of prevention model encompassing multiple strategies is also referred to as the Universal, Selective, Indicated (USI) Model.^7,8,10 The VHA suicide prevention program contains a wide spread of program components, making it both comprehensive and innovative (Table 1).

Although significant momentum and progress has been made within the VHA, policy set by legislation has historically limited access to VHA health care services to VHA-eligible veterans. This is particularly concerning given the rising suicide rates among veterans not engaged in VHA care.² Adding to this complexity, recent legislation has increased veterans’ access to non-VHA health care, in addition to their existing access through Medicare, Medicaid, and other health care programs.^12-14 Best practices for suicide prevention are not often implemented in the private sector; thus, these systems are ill prepared to adequately meet the suicide prevention care needs of veterans.^4,15-18 Furthermore, VHA and non-VHA services generally are not well coordinated, and private sector health care providers (HCPs) are not required to complete a commensurate level of suicide prevention training as are VHA HCPs.^16-18 Most non-VHA HCPs do not receive military cultural competence training.¹⁹ These issues create a significant gap in suicide prevention services and may contribute to the increases in suicide rates in veterans who do not receive VHA care. Thus, changes in policy to increase access through private sector care may have paradoxical effects on veteran suicide deaths. To impact the veteran suicide rate, VHA must develop and disseminate best practices for veterans who use non-VHA services.

A Roadmap to Suicide Prevention

There is significant momentum at the federal level regarding this issue. The President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (Executive Order 13,861) directs the VHA to work closely with community organizations to improve veteran suicide prevention.²⁰ The VHA and partners, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), are bridging this gap with collaborative efforts that increase suicide prevention resources for veterans living in the community through programs such as the Governor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families. These programs intend to empower communities to develop statewide, strategic action plans to prevent veteran suicide.^7,21-24

In addition to partnerships, VHA has built other aspects of outreach and intervention into its programming. A key VHA initiative is to “know all veterans” by committing to identifying and reaching out to all veterans who may be at risk for suicide.²² The VHA has committed to offering “emergency stabilization care for former service members who present at the facility with an emergent mental health need” regardless of eligibility.²⁵ The intent is to provide temporary emergent mental health care to veterans who are otherwise ineligible for care, such as those who were discharged under other-than-honorable conditions while the VHA determines eligibility status.²⁶ However, veterans must meet certain criteria, and there is a limit on services.

Although services are being expanded to reach veterans who do not access VHA health care, how to best implement these new directives with regard to suicide prevention is unclear. Strategic development and innovations to expand suicide prevention care to veterans outside the current reach of VHA are desperately needed.

Program Overview 

VHA Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), funded by the VHA National Center for Patient Safety, aims to help fill the gap in community-based suicide prevention for veterans. PSCI-SPC is located within the VHA Rocky Mountain Mental Illness Research, Education, and Clinical Center in Aurora, Colorado. The overarching mission of PSCI-SPC is to develop, implement, and evaluate practical solutions to reduce suicide among veterans not receiving VHA care. PSCI-SPC serves as a national clinical innovation and dissemination center for best practices in suicide prevention for organizations that serve veterans who receive care in the community. PSCI-SPC creates products to support dissemination of these practices to other VAMCs and works to ensure these programs are sustainable. PSCI-SPC focuses on 3 primary objectives. All PSCI-SPC projects are currently underway.

Objective 1: Growing a Community Learning Collaborative

Acknowledging that nearly two-thirds of veterans who die by suicide do not use VHA services, PSCI-SPC aims to reduce suicide among all veterans by expanding the reach of best practices for suicide prevention to veterans who receive myriad services in the community.²⁷ Community organizations are defined here as organizations that may in some way serve, interact with, or work with veterans, and/or employ veterans. Examples include non-VHA health care systems, public services such as police and fire departments, nonprofit organizations, mental health clinics, and veterans’ courts. As veterans increasingly seek health care and other services within their communities, the success of suicide prevention will be influenced by the capability of non-VHA public and private organizations. Objective 1, therefore, seeks to develop a VHA-community collaborative that can be leveraged to improve systems of suicide prevention.

Current programs in the VHA have focused on implementation of suicide prevention awareness and prevention education campaigns instead of grassroots partnerships that are intended to be sustainable. Additionally, these programs typically lack the capacity and systems to sustain numerous meaningful community partnerships. Traditionally, community organizations have been hesitant to partner with government agencies, such as the VHA, due to histories of institutional mistrust and bureaucracy.²⁸

The PSCI-SPC model for developing a VHA-community collaborative partnership draws from the tradition of community-based participatory research. The best community-based participatory research practices are to build on strengths and resources within the local community; develop collaborative, equitable partnerships that involve an empowering and power-sharing process; foster colearning, heuristics, and capacity building among partners; and focus on systems development using an iterative process. These practices also are consistent with the literature on learning collaboratives.^29-31

The premise for a learning collaborative is to bridge the gap between knowledge and practice in health care.³¹ Figure 1 depicts how this collaborative was developed, and how it supports Objectives 2 and 3. To achieve Objective 1, we developed a VHA-learning collaborative of 13 influential community partners in the Denver and Colorado Springs region of Colorado. The VHA team consists of a learning collaborative leader, a program manager, and a program support assistant. The principal investigator attends and contributes to all meetings. Learning collaborative partners include a university psychology clinic that focuses on veterans’ care, 3 veterans service organizations, a mental health private practice, a university school of nursing, a community mental health center, veterans’ courts, and 5 city departments.

Objective 2: Implementation Toolkit

The second PSCI-SPC objective is to develop a toolkit for the implementation of best practices within a VHA-community suicide prevention learning collaborative. Lessons from the development of a successful suicide prevention learning collaborative will be shared through an online guide that other VHA facilities can use to support similar collaborative efforts within their communities. The toolkit will be disseminated across the VHA to assist suicide prevention coordinators and other staff in developing a suicide prevention learning collaborative at their facilities.

PSCI-SPC uses the Zero Suicide framework and the VA/US Department of Defense (DoD) Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide as models for preventing suicide in veterans not enrolled in VHA care.^11,32 This implementation toolkit focuses on how to implement suicide prevention best practices into organizations that serve veterans. This toolkit differs from clinical practice guidelines in that it focuses on implementation strategies to promote success and effectively address challenges.

In order to provide a menu of available options for the learning collaborative and resulting toolkit, PSCI-SPC uses a logic model to compare the components of the VHA suicide prevention program, as well as other similar veteran and military suicide prevention programs.^{7,12,14,21,33,34} These programs are categorized into 2 types of prevention frameworks, the USI model as described above, and the SAMHSA Strategic Prevention Framework (Table 2).³⁵ The SAMHSA framework was designed to promote mental health and prevent substance abuse, yet the derived classification is also applicable to suicide prevention programs.³⁵ The results of the logic model comparison form the basis of the best practice interventions for the learning collaborative and initial toolkit. In addition to the best practice interventions, the toolkit consists of documents describing how to develop a veteran suicide prevention learning collaborative, as well as tools for learning collaborative members. Current tool development includes workbooks to guide collaborative members through the implementation process, guides for community organizations in implementing suicide prevention screening and risk assessment, a standard operating procedure for suicide prevention in a veterans court, and peer support training for veteran suicide prevention.

Objective 3: High-Risk Veterans Not Receiving VHA Care

Although veterans not receiving VHA care account for a number of veteran deaths by suicide, we are not aware of any current VHA programs that provide temporary psychotherapy and intensive case management to at-risk veterans ineligible for VHA care who are in need of immediate care while an appropriate permanent community placement is identified. In the current system, veterans in the community can present to VHA suicide prevention services through several different systems, including referrals to VHA and the Veterans Crisis Line (VCL). However, a portion of VCL calls are from veterans whose VHA eligibility is unknown or who are ineligible for services. If veterans are at imminent risk for suicide, emergency care is coordinated for them. However, if veterans are not at imminent suicide risk they are referred to the local suicide prevention coordinator and instructed to independently work toward determining their VHA eligibility.

It is currently unknown how many veterans follow through with these instructions. Nonetheless, if veterans are deemed eligible, they may present to VHA to obtain a same-day appointment. If not eligible, a suicide prevention coordinator may give them the phone number of a community referral. However, this practice is not standardized across VA medical centers, and the provided resources are up to the suicide prevention coordinator to research. Additionally, when a VHA suicide prevention coordinator leaves the position, knowledge of these community resources and rapport with community HCPs are often lost, leaving the next coordinator to develop these again, which reduces the efficiency and effectiveness of limited resources. It is also unknown how many veterans complete this contact and receive evidence-based treatment following referral. This is a complex system to navigate, particularly when at risk for suicide and in need of immediate but not emergency services.

Suicide prevention in such circumstances may be improved by adapting current suicide prevention practices, including evidence-based interventions, and the new VHA intensive case management program,^11,36 within a Zero Suicide framework. PSCI-SPC has developed a brief intervention to transition ineligible veterans to permanent community treatment and provide them with additional resources to meet their varied needs. The brief 1 to 3 session intervention combines practices from brief cognitive behavioral therapy (BCBT) for suicide prevention, crisis response planning (CRP), and intensive case management within a Zero Suicide framework. Both the 2019 VA/DoD suicide prevention clinical practice guidelines and Zero Suicide recommend using cognitive behavioral therapy (CBT)-based interventions for suicide prevention.^11,32 These interventions are packaged into a single intervention delivered by a PSCI-SPC therapist, typically a licensed clinical social worker, a licensed clinical psychologist, or an unlicensed psychologist under the supervision of a licensed clinical psychologist.

BCBT is one type of CBT that has shown initial efficacy in reducing suicide attempts.³⁷ BCBT reduces the risk for suicide attempts both at the conclusion of treatment and at 24-month follow-up.³⁷ BCBT is boiled down to its most essential components so it can be delivered in a distilled format. An essential element of BCBT that will remain is the CRP. A CRP^11,37,38 entails collaboratively identifying effective, appropriate coping strategies and specific individuals to contact during a crisis. CRPs demonstrated efficacy as a stand-alone intervention to existing suicide prevention methods in a randomized clinical trial, such that individuals who received CRP had faster reductions in suicidal ideation and were 76% less likely to make a suicide attempt during the 6-month follow-up period.³⁹ These results demonstrate that use of a CRP is connected to a decrease in suicidal behavior among suicidal patients.

The VHA has developed and is piloting a new initiative focused on restructuring its intensive case management services. RACETIME to Integrated Care (eg, Risk stratification, Assessment of complexity, Coordinator of lead assignment, Evaluate whole health needs, Trusting partnerships, Integrate care, Monitor progress, Experience of the veteran and employee) is a framework that assists VHA case managers in transitioning from a traditional case management mind-set to a more integrated and holistic method of care.³⁶ RACETIME intensive case management practices will be incorporated into the intervention. However, RACETIME focuses on case management internally to the VHA. A modification for this treatment will be to focus on intensive case management from a mental health perspective and connecting to external community resources. Community referrals are mapped within a structured process and stored on a shared drive. This improves continuity between suicide prevention coordinators when they leave for a new position.

This intervention is conducted within a Zero Suicide framework. Pertinent to PSCI-SPC innovation to enhance care for non-VHA veterans is the care transitions element within the Zero Suicide framework, which has developed comprehensive suicide prevention guidance, including a pathway to care.³² This pathway refers a process to conduct follow-up supportive contacts that are tracked and recorded.

The PSCI-SPC pilot program incorporates the elements of CRP and brief CBT within a Zero Suicide framework. The PSCI-SPC team is developing and testing a protocol for providing brief treatment and community referrals to ineligible veterans that integrates these programming elements (Figure 2). A PSCI-SPC social worker will coordinate with the eligibility office to determine VHA eligibility. Ineligible veterans are referred to community partners and nonenrolled, eligible veterans are linked to VHA HCPs if they desire. These transitions will be coordinated, closely monitored, and verified. The PSCI-SPC team receives referrals from the VCL and other VHA programs that are in contact with ineligible veterans. Other program eligibility criteria include meeting 1 of 3 criteria: (1) a lifetime suicide attempt; (2) suicidal ideation in the past 6 months; or (3) a current mental health disorder. At the outset of the program, it is explained that the purpose of the intervention is to provide short-term, transitional services to assist the veteran in attaining a permanent mental health placement.

Discussion

Improving suicide prevention for veterans who receive non-VHA health care is essential to significantly reduce veteran suicide rates. For the past decade, VHA suicide prevention initiatives have largely focused on veterans eligible for care, although the fastest increase in veteran suicide rates has occurred among veterans not connected to VHA services. Currently, if a veteran is deemed ineligible for care, it is up to the veteran to find other health care services in his or her community. There is not always a clear next step for the veteran to take, nor clear guidance provided to the VHA registration staff to assist with this care transition. This is particularly concerning for veterans at high risk for suicide as this could further thwart the veteran’s sense of belongingness and increase perceived burdensomeness, both suicide risk factors, and discourage them from attaining help.⁴⁰ Overall, while the VHA has successfully implemented diverse suicide prevention initiatives and services, the need for continued system improvement focused on non-VHA veterans remains. PSCI-SPC was developed for this purpose.

By creating a collaborative that will connect VHA and community organizations, there will be better utilization of resources and more appropriate referrals throughout systems that interact with veterans. Sharing suicide prevention best practices between VHA and community partners is expected to increase access to mental health treatment to all veterans. Finally, by allowing best practices for suicide prevention in the VHA to serve as a guide in the development of best practices for suicide prevention between the VHA and the local health and behavioral health care community, PSCI-SPC will create a new suicide prevention intervention for veterans with mental health needs. Through these initiatives, PSCI-SPC will support providers’ and concerned citizens’ efforts to ensure that fewer veterans fall through the cracks of disjointed systems and will promote healthier communities where, regardless of VHA enrollment status, veterans receive suicide prevention care.

Conclusions

PSCI-SPC is a novel center for the innovation and dissemination of the nation’s best practices in suicide prevention for veterans who are ineligible for or otherwise not engaged in VHA services and who turn to their community for health care. PSCI-SPC not only seeks to create, develop, and measure various solutions to reduce suicide among veterans who receive non-VHA care, but also seeks to facilitate the overall quality of existing practices for suicide prevention and care coordination for enrolled veterans who use community resources. By bridging the gap between the VHA, civilian health care systems, and other community partners striving to prevent veteran suicides, we can create better access to care and a more seamless path of communication among these important entities that impact the lives of our veterans daily

Since 2008, suicide has ranked as the tenth leading cause of death for all ages in the US, with rates of suicide continuing to rise.^1-3 Suicide is even more urgent to address in veteran populations. The age- and sex-adjusted suicide rate in 2017 was more than 1.5 times greater for veterans than it was for nonveteran adults.² Of importance, rates of suicide are increasing at a faster rate in veterans who are not connected to Veterans Health Administration (VHA) care.^4,5 These at-risk veterans include individuals who are eligible for VHA care yet have not had a VHA appointment within the year before death; veterans who may be ineligible to receive VHA care due to complex rules set by legislation; and veterans who are eligible but not enrolled in VHA care. Notably, between 2005 and 2016, the number of veterans not enrolled in VHA care rose more quickly than did the number of veterans enrolled in VHA care.^5,6 Thus, to impact the high veteran suicide rates, an emergent challenge for VHA is to prevent suicide among unenrolled veterans and veterans receiving community care, while continuing to increase access to mental health services for veterans enrolled in VHA health care.

In response to the high rates of veteran suicide deaths, the US Department of Veterans Affairs (VA) has developed a broad, multicomponent suicide prevention program that is unparalleled in private US health care systems.^4,7 Suicide prevention efforts are led and implemented by both the VHA National Center for Patient Safety and the VHA Office of Mental Health and Suicide Prevention. Program components are numerous and multifaceted, falling within the broad promotion and prevention strategies outlined by the National Academy of Medicine (NAM).^1,8-11 The NAM continuum of prevention model encompassing multiple strategies is also referred to as the Universal, Selective, Indicated (USI) Model.^7,8,10 The VHA suicide prevention program contains a wide spread of program components, making it both comprehensive and innovative (Table 1).

Although significant momentum and progress has been made within the VHA, policy set by legislation has historically limited access to VHA health care services to VHA-eligible veterans. This is particularly concerning given the rising suicide rates among veterans not engaged in VHA care.² Adding to this complexity, recent legislation has increased veterans’ access to non-VHA health care, in addition to their existing access through Medicare, Medicaid, and other health care programs.^12-14 Best practices for suicide prevention are not often implemented in the private sector; thus, these systems are ill prepared to adequately meet the suicide prevention care needs of veterans.^4,15-18 Furthermore, VHA and non-VHA services generally are not well coordinated, and private sector health care providers (HCPs) are not required to complete a commensurate level of suicide prevention training as are VHA HCPs.^16-18 Most non-VHA HCPs do not receive military cultural competence training.¹⁹ These issues create a significant gap in suicide prevention services and may contribute to the increases in suicide rates in veterans who do not receive VHA care. Thus, changes in policy to increase access through private sector care may have paradoxical effects on veteran suicide deaths. To impact the veteran suicide rate, VHA must develop and disseminate best practices for veterans who use non-VHA services.

A Roadmap to Suicide Prevention

There is significant momentum at the federal level regarding this issue. The President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (Executive Order 13,861) directs the VHA to work closely with community organizations to improve veteran suicide prevention.²⁰ The VHA and partners, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), are bridging this gap with collaborative efforts that increase suicide prevention resources for veterans living in the community through programs such as the Governor’s Challenges to Prevent Suicide Among Service Members, Veterans, and their Families. These programs intend to empower communities to develop statewide, strategic action plans to prevent veteran suicide.^7,21-24

In addition to partnerships, VHA has built other aspects of outreach and intervention into its programming. A key VHA initiative is to “know all veterans” by committing to identifying and reaching out to all veterans who may be at risk for suicide.²² The VHA has committed to offering “emergency stabilization care for former service members who present at the facility with an emergent mental health need” regardless of eligibility.²⁵ The intent is to provide temporary emergent mental health care to veterans who are otherwise ineligible for care, such as those who were discharged under other-than-honorable conditions while the VHA determines eligibility status.²⁶ However, veterans must meet certain criteria, and there is a limit on services.

Although services are being expanded to reach veterans who do not access VHA health care, how to best implement these new directives with regard to suicide prevention is unclear. Strategic development and innovations to expand suicide prevention care to veterans outside the current reach of VHA are desperately needed.

Program Overview 

VHA Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), funded by the VHA National Center for Patient Safety, aims to help fill the gap in community-based suicide prevention for veterans. PSCI-SPC is located within the VHA Rocky Mountain Mental Illness Research, Education, and Clinical Center in Aurora, Colorado. The overarching mission of PSCI-SPC is to develop, implement, and evaluate practical solutions to reduce suicide among veterans not receiving VHA care. PSCI-SPC serves as a national clinical innovation and dissemination center for best practices in suicide prevention for organizations that serve veterans who receive care in the community. PSCI-SPC creates products to support dissemination of these practices to other VAMCs and works to ensure these programs are sustainable. PSCI-SPC focuses on 3 primary objectives. All PSCI-SPC projects are currently underway.

Objective 1: Growing a Community Learning Collaborative

Acknowledging that nearly two-thirds of veterans who die by suicide do not use VHA services, PSCI-SPC aims to reduce suicide among all veterans by expanding the reach of best practices for suicide prevention to veterans who receive myriad services in the community.²⁷ Community organizations are defined here as organizations that may in some way serve, interact with, or work with veterans, and/or employ veterans. Examples include non-VHA health care systems, public services such as police and fire departments, nonprofit organizations, mental health clinics, and veterans’ courts. As veterans increasingly seek health care and other services within their communities, the success of suicide prevention will be influenced by the capability of non-VHA public and private organizations. Objective 1, therefore, seeks to develop a VHA-community collaborative that can be leveraged to improve systems of suicide prevention.

Current programs in the VHA have focused on implementation of suicide prevention awareness and prevention education campaigns instead of grassroots partnerships that are intended to be sustainable. Additionally, these programs typically lack the capacity and systems to sustain numerous meaningful community partnerships. Traditionally, community organizations have been hesitant to partner with government agencies, such as the VHA, due to histories of institutional mistrust and bureaucracy.²⁸

The PSCI-SPC model for developing a VHA-community collaborative partnership draws from the tradition of community-based participatory research. The best community-based participatory research practices are to build on strengths and resources within the local community; develop collaborative, equitable partnerships that involve an empowering and power-sharing process; foster colearning, heuristics, and capacity building among partners; and focus on systems development using an iterative process. These practices also are consistent with the literature on learning collaboratives.^29-31

The premise for a learning collaborative is to bridge the gap between knowledge and practice in health care.³¹ Figure 1 depicts how this collaborative was developed, and how it supports Objectives 2 and 3. To achieve Objective 1, we developed a VHA-learning collaborative of 13 influential community partners in the Denver and Colorado Springs region of Colorado. The VHA team consists of a learning collaborative leader, a program manager, and a program support assistant. The principal investigator attends and contributes to all meetings. Learning collaborative partners include a university psychology clinic that focuses on veterans’ care, 3 veterans service organizations, a mental health private practice, a university school of nursing, a community mental health center, veterans’ courts, and 5 city departments.

Objective 2: Implementation Toolkit

The second PSCI-SPC objective is to develop a toolkit for the implementation of best practices within a VHA-community suicide prevention learning collaborative. Lessons from the development of a successful suicide prevention learning collaborative will be shared through an online guide that other VHA facilities can use to support similar collaborative efforts within their communities. The toolkit will be disseminated across the VHA to assist suicide prevention coordinators and other staff in developing a suicide prevention learning collaborative at their facilities.

PSCI-SPC uses the Zero Suicide framework and the VA/US Department of Defense (DoD) Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide as models for preventing suicide in veterans not enrolled in VHA care.^11,32 This implementation toolkit focuses on how to implement suicide prevention best practices into organizations that serve veterans. This toolkit differs from clinical practice guidelines in that it focuses on implementation strategies to promote success and effectively address challenges.

In order to provide a menu of available options for the learning collaborative and resulting toolkit, PSCI-SPC uses a logic model to compare the components of the VHA suicide prevention program, as well as other similar veteran and military suicide prevention programs.^{7,12,14,21,33,34} These programs are categorized into 2 types of prevention frameworks, the USI model as described above, and the SAMHSA Strategic Prevention Framework (Table 2).³⁵ The SAMHSA framework was designed to promote mental health and prevent substance abuse, yet the derived classification is also applicable to suicide prevention programs.³⁵ The results of the logic model comparison form the basis of the best practice interventions for the learning collaborative and initial toolkit. In addition to the best practice interventions, the toolkit consists of documents describing how to develop a veteran suicide prevention learning collaborative, as well as tools for learning collaborative members. Current tool development includes workbooks to guide collaborative members through the implementation process, guides for community organizations in implementing suicide prevention screening and risk assessment, a standard operating procedure for suicide prevention in a veterans court, and peer support training for veteran suicide prevention.

Objective 3: High-Risk Veterans Not Receiving VHA Care

Although veterans not receiving VHA care account for a number of veteran deaths by suicide, we are not aware of any current VHA programs that provide temporary psychotherapy and intensive case management to at-risk veterans ineligible for VHA care who are in need of immediate care while an appropriate permanent community placement is identified. In the current system, veterans in the community can present to VHA suicide prevention services through several different systems, including referrals to VHA and the Veterans Crisis Line (VCL). However, a portion of VCL calls are from veterans whose VHA eligibility is unknown or who are ineligible for services. If veterans are at imminent risk for suicide, emergency care is coordinated for them. However, if veterans are not at imminent suicide risk they are referred to the local suicide prevention coordinator and instructed to independently work toward determining their VHA eligibility.

It is currently unknown how many veterans follow through with these instructions. Nonetheless, if veterans are deemed eligible, they may present to VHA to obtain a same-day appointment. If not eligible, a suicide prevention coordinator may give them the phone number of a community referral. However, this practice is not standardized across VA medical centers, and the provided resources are up to the suicide prevention coordinator to research. Additionally, when a VHA suicide prevention coordinator leaves the position, knowledge of these community resources and rapport with community HCPs are often lost, leaving the next coordinator to develop these again, which reduces the efficiency and effectiveness of limited resources. It is also unknown how many veterans complete this contact and receive evidence-based treatment following referral. This is a complex system to navigate, particularly when at risk for suicide and in need of immediate but not emergency services.

Suicide prevention in such circumstances may be improved by adapting current suicide prevention practices, including evidence-based interventions, and the new VHA intensive case management program,^11,36 within a Zero Suicide framework. PSCI-SPC has developed a brief intervention to transition ineligible veterans to permanent community treatment and provide them with additional resources to meet their varied needs. The brief 1 to 3 session intervention combines practices from brief cognitive behavioral therapy (BCBT) for suicide prevention, crisis response planning (CRP), and intensive case management within a Zero Suicide framework. Both the 2019 VA/DoD suicide prevention clinical practice guidelines and Zero Suicide recommend using cognitive behavioral therapy (CBT)-based interventions for suicide prevention.^11,32 These interventions are packaged into a single intervention delivered by a PSCI-SPC therapist, typically a licensed clinical social worker, a licensed clinical psychologist, or an unlicensed psychologist under the supervision of a licensed clinical psychologist.

BCBT is one type of CBT that has shown initial efficacy in reducing suicide attempts.³⁷ BCBT reduces the risk for suicide attempts both at the conclusion of treatment and at 24-month follow-up.³⁷ BCBT is boiled down to its most essential components so it can be delivered in a distilled format. An essential element of BCBT that will remain is the CRP. A CRP^11,37,38 entails collaboratively identifying effective, appropriate coping strategies and specific individuals to contact during a crisis. CRPs demonstrated efficacy as a stand-alone intervention to existing suicide prevention methods in a randomized clinical trial, such that individuals who received CRP had faster reductions in suicidal ideation and were 76% less likely to make a suicide attempt during the 6-month follow-up period.³⁹ These results demonstrate that use of a CRP is connected to a decrease in suicidal behavior among suicidal patients.

The VHA has developed and is piloting a new initiative focused on restructuring its intensive case management services. RACETIME to Integrated Care (eg, Risk stratification, Assessment of complexity, Coordinator of lead assignment, Evaluate whole health needs, Trusting partnerships, Integrate care, Monitor progress, Experience of the veteran and employee) is a framework that assists VHA case managers in transitioning from a traditional case management mind-set to a more integrated and holistic method of care.³⁶ RACETIME intensive case management practices will be incorporated into the intervention. However, RACETIME focuses on case management internally to the VHA. A modification for this treatment will be to focus on intensive case management from a mental health perspective and connecting to external community resources. Community referrals are mapped within a structured process and stored on a shared drive. This improves continuity between suicide prevention coordinators when they leave for a new position.

This intervention is conducted within a Zero Suicide framework. Pertinent to PSCI-SPC innovation to enhance care for non-VHA veterans is the care transitions element within the Zero Suicide framework, which has developed comprehensive suicide prevention guidance, including a pathway to care.³² This pathway refers a process to conduct follow-up supportive contacts that are tracked and recorded.

The PSCI-SPC pilot program incorporates the elements of CRP and brief CBT within a Zero Suicide framework. The PSCI-SPC team is developing and testing a protocol for providing brief treatment and community referrals to ineligible veterans that integrates these programming elements (Figure 2). A PSCI-SPC social worker will coordinate with the eligibility office to determine VHA eligibility. Ineligible veterans are referred to community partners and nonenrolled, eligible veterans are linked to VHA HCPs if they desire. These transitions will be coordinated, closely monitored, and verified. The PSCI-SPC team receives referrals from the VCL and other VHA programs that are in contact with ineligible veterans. Other program eligibility criteria include meeting 1 of 3 criteria: (1) a lifetime suicide attempt; (2) suicidal ideation in the past 6 months; or (3) a current mental health disorder. At the outset of the program, it is explained that the purpose of the intervention is to provide short-term, transitional services to assist the veteran in attaining a permanent mental health placement.

Discussion

Improving suicide prevention for veterans who receive non-VHA health care is essential to significantly reduce veteran suicide rates. For the past decade, VHA suicide prevention initiatives have largely focused on veterans eligible for care, although the fastest increase in veteran suicide rates has occurred among veterans not connected to VHA services. Currently, if a veteran is deemed ineligible for care, it is up to the veteran to find other health care services in his or her community. There is not always a clear next step for the veteran to take, nor clear guidance provided to the VHA registration staff to assist with this care transition. This is particularly concerning for veterans at high risk for suicide as this could further thwart the veteran’s sense of belongingness and increase perceived burdensomeness, both suicide risk factors, and discourage them from attaining help.⁴⁰ Overall, while the VHA has successfully implemented diverse suicide prevention initiatives and services, the need for continued system improvement focused on non-VHA veterans remains. PSCI-SPC was developed for this purpose.

By creating a collaborative that will connect VHA and community organizations, there will be better utilization of resources and more appropriate referrals throughout systems that interact with veterans. Sharing suicide prevention best practices between VHA and community partners is expected to increase access to mental health treatment to all veterans. Finally, by allowing best practices for suicide prevention in the VHA to serve as a guide in the development of best practices for suicide prevention between the VHA and the local health and behavioral health care community, PSCI-SPC will create a new suicide prevention intervention for veterans with mental health needs. Through these initiatives, PSCI-SPC will support providers’ and concerned citizens’ efforts to ensure that fewer veterans fall through the cracks of disjointed systems and will promote healthier communities where, regardless of VHA enrollment status, veterans receive suicide prevention care.

Conclusions

PSCI-SPC is a novel center for the innovation and dissemination of the nation’s best practices in suicide prevention for veterans who are ineligible for or otherwise not engaged in VHA services and who turn to their community for health care. PSCI-SPC not only seeks to create, develop, and measure various solutions to reduce suicide among veterans who receive non-VHA care, but also seeks to facilitate the overall quality of existing practices for suicide prevention and care coordination for enrolled veterans who use community resources. By bridging the gap between the VHA, civilian health care systems, and other community partners striving to prevent veteran suicides, we can create better access to care and a more seamless path of communication among these important entities that impact the lives of our veterans daily

Atypical antipsychotic use may result in metabolic abnormalities, such as hyperglycemia, dyslipidemia, weight gain, and metabolic syndrome. These adverse effects (AEs) can cause progression to type 2 diabetes mellitus (T2DM) as well as increased risk of cardiovascular disease and cardiac mortality. Individuals diagnosed with T2DM have medical expenses that are about 2.3 times higher than individuals without diabetes.^1,2 The risk of experiencing metabolic abnormalities is likely elevated for patients who were antipsychotic-naïve prior to initiation.³

In response to an increased awareness of atypical antipsychotic-related AEs, the American Diabetes Association (ADA) and American Psychiatric Association (APA) released a consensus statement in 2004 with a metabolic monitoring protocol for patients initiating or changing to a new antipsychotic medication.⁴ Within the first year after initiation, the ADA/APA consensus statements recommends that clinicians acquire a personal and family history, weight, body mass index (BMI), waist circumference, blood pressure (BP), fasting plasma glucose, and fasting lipid profile at the initial patient visit. Patient weight is recommended to be collected at 4 weeks and again 8 weeks later. Twelve weeks after the initial visit, weight, BMI, BP, fasting plasma glucose and a fasting lipid profile are recommended to be collected and assessed for abnormalities. Weight is then recommended to be assessed every 3 months thereafter. Review of personal and family history, waist circumference, BP, and a fasting plasma glucose is recommended to occur annually. Finally, a fasting lipid profile is to be collected every 5 years.

Since the initial consensus statement release, metabolic monitoring of patients prescribed antipsychotic medications has been found to be inadequate within several large health care organizations.^5,6 Mittal and colleagues reviewed metabolic monitoring practices occurring in 32 facilities within the Veterans Health Administration (VHA) and found that monitoring practices in the first 90 days after antipsychotic initiation were largely nonadherent to the ADA/APA consensus statement recommendations.⁶ Medical staff in Veterans Integrated Service Network 21 (VISN 21) currently serve about 268,000 veterans actively receiving care across California, Nevada, and the Pacific Islands.To support veteran care in the fields of mental health and medication safety, the VISN 21 pharmacy benefits manager office created a clinical dashboard that identifies veterans who are currently prescribed an antipsychotic and have not completed at least 1 annual blood glucose test. While this dashboard is a valuable tool for tracking patient care for those who have been prescribed an antipsychotic > 1 year, it does not consider the ADA/APA recommendations for more frequent monitoring in the first year after initiation. A literature review found no citations of a systematic evaluation of adherence to ADA/APA monitoring recommendations or patient progression to T2DM in the first year after antipsychotic initiation for an antipsychotic-naïve veteran population. The goal of this quality improvement project is to assess VHA health care provider and patient adherence to the 2004 consensus statement recommendations within the first year after initiation for previously antipsychotic-naïve patients receiving an atypical antipsychotic and determine rate of progression to T2DM.

Methods

The project was reviewed by the University of Nevada-Reno Institutional Review Board and determined to be a nonresearch quality improvement project. This was a retrospective chart analysis that included patients receiving their first-ever atypical antipsychotic across 8 US Department of Veterans Affairs (VA) medical centers within VISN 21. Clinical patient data, including prescription, vital sign, and laboratory information, were extracted from the VA Corporate Data Warehouse using transact sequential query language.

Veterans were included in the final cohort if they met the following criteria: aged ≥ 18 years at antipsychotic initiation, initiated their first-ever atypical antipsychotic within the VHA between February 2014 and February 2019, continued the antipsychotic for ≥ 1 year, had a medication possession ratio (MPR) > 80%, and had previously established care within VHA as evidenced by having ≥ 1 primary care or outpatient mental health visit in the 6 months prior to initiation. The MPR is defined as the sum of the day’s supply of all dispensed medications in the project time frame divided by the total number of days in the project time frame.

Veterans were excluded if they initiated any other antipsychotic during the first course, had a prior diagnosis of T2DM, had any prior use of antidiabetic medications, or had a hemoglobin A_1c (HbA_1c) > 6.4 in the year prior to initiation.

The primary outcome was completion of all recommended metabolic monitoring time points in the first year after atypical antipsychotic initiation. The secondary outcome was incidence of T2DM as evidenced by either a HbA_1c > 6.4 or diagnosis of T2DM entered into the electronic health record. Baseline monitoring for BP, blood glucose, and lipids were considered complete if a data point was collected between 3 months prior and 1 month after atypical antipsychotic initiation. Baseline monitoring for weight was considered complete if a data point was collected between 3 months prior and 2 weeks after initiation. Follow-up monitoring for BP, blood glucose, and lipids were considered completed if a data point was collected at 3 and 12 months (mean, 1 month). Follow-up monitoring for weight was considered completed if collected at 1, 2, and 3 months (mean, 2 weeks) and at 6, 9, and 12 months (mean, 1 month). Waist circumference data and patient and family history are not collected as capturable data points. Therefore, the authors were unable to include these in the final data extraction.

Results

The final cohort consisted of 1,651 veterans who met the inclusion criteria. Overall, at antipsychotic initiation the cohort had a mean (SD) age of 55 (14.6) years, was largely male (88%), and was considered overweight with a mean (SD) BMI of 29.1 (6.4) (Table 1).

Appropriate BP monitoring was completed most often with 492 patients (30%) meeting ADA/APA recommendations followed by HbA_1c and/or blood glucose monitoring with 203 patients (12%) completing all time points. Recommended lipid monitoring was completed by 96 patients (6%). Weight monitoring was completed least often with 47 patients (3%) completing all recommended time points. Regarding completion of all metabolic monitoring time points, 3 (0.2%) patients in the final cohort were found to have completed all recommended monitoring. Ninety-nine patients (6%) were found to have progressed to T2DM as indicated by an HbA_1c > 6.4 and/or entry of a T2DM ninth or tenth edition International Statistical Classification of Diseases code into the chart (Table 2).

Discussion

No previous literature exists that reviews adherence to recommended metabolic monitoring guidance up to 1 year after antipsychotic initiation in a previously antipsychotic-naïve cohort within the VHA. Metabolic monitoring was overall incomplete with 0.2% of the cohort completing all recommended monitoring time points. Weight was the parameter that was least completed. Based on these findings, the authors concluded that efforts are needed to improve completion rates of atypical antipsychotic metabolic monitoring. In the final cohort, 6% of patients were noted to have progressed to T2DM in the first year after atypical antipsychotic initiation. The actual number of patients progressing to T2DM may be larger because not all received adequate blood glucose monitoring. For comparison, the Centers for Disease Control and Prevention released information in 2015 that stated that the US population has an annual T2DM incidence of about 1% for adults aged 45 to 64 years.⁷

We understand that individuals with mental health disorders are at increased risk of T2DM compared with that of the general population and hope that this comparison only serves to drive home the point that appropriate metabolic monitoring is vital for this subgroup. The strengths of this project include identification of an area for improvement and encouraging evidence-based monitoring. Utilization of clinical data is a cost-effective and efficient method to improve patient care.

Limitations

Limitations of this study include the data’s dependence on accuracy of entry by the end-user and a lack of available data regarding prescriptions dispensed outside of the VHA. Vital signs data may have been entered into patient notes and not documented in the vitals section of the current medical record causing the appearance of missing data. Access to VHA health services and patient adherence to follow-up appointments were not assessed in this project and could affect patient ability to complete follow-up. The final analysis included only patients who remained on 1 atypical antipsychotic for a year and were considered adherent with an MPR > 80% and did not consider less adherent patients. It is also possible that health care providers who closely monitor metabolic parameters after atypical antipsychotic initiation more frequently switch patients to an alternative atypical antipsychotic while others who monitor less also switch medications less frequently. This could lead to selection of patients with health care providers who are less adherent to metabolic monitoring recommendations.

Conclusions

As a result of this study, in VISN 21 several strategies will be implemented to improve monitoring. First, the results of this project will be shared with the subject matter experts of the VISN 21 Mental Health Task Force. This task force serves as a venue for clinicians to meet virtually, discuss clinical topics, as well as to create and distribute strategies to improve patient care. Clinicians at this forum will be encouraged to implement monitoring protocols into routine practice, share best practices with colleagues, and increase patient awareness about the importance of metabolic monitoring. Second, modifications may be applied to the electronic health record to guide metabolic monitoring order entry at the time of prescription entry, which includes development of clinical reminders and laboratory order sets. Third, the clinical data manager team may be leveraged to create an electronic report identifying patients currently receiving suboptimal monitoring in the first year after antipsychotic initiation. The patients identified in this report will be discussed at the recurring VISN 21 Mental Health Task Force meeting, and strong practices will be shared with the medical centers across VISN 21. Other strategies under consideration include requiring proof of metabolic monitoring completion prior to allowing further atypical antipsychotic refills and providing direct provider education regarding the ADA/APA metabolic monitoring recommendations via the academic detailing service in effort to standardize clinical care.