The federal government declared a formal public health emergency on Jan. 31 to aid in the response to the 2019 Novel Coronavirus (2019-nCoV). The declaration, issued by Health and Human Services Secretary Alex. M. Azar II gives state, tribal, and local health departments additional flexibility to request assistance from the federal government in responding to the coronavirus.

"While this virus poses a serious public health threat, the risk to the American public remains low at this time, and we are working to keep this risk low."*

The government also began a quarantine of travelers. The 195 passengers who arrived at March Air Reserve Base in Ontario, Calif., from Wuhan, China on Jan. 29 are under federal quarantine amid growing concerns about the 2019-nCoV—the first such action taken by the Centers for Disease Control and Prevention in more than 50 years.

“This decision is based on the current scientific facts,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during a press briefing Jan. 31. “While we understand the action seems drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for over-reacting than under-reacting.”

These actions come on the heels of the World Health Organization’s Jan. 30 declaration of 2019-nCoV as a public health emergency of international concern, and from a recent spike in cases reported by Chinese health officials. “Every day this week China has reported additional cases,” Dr. Messonnier said. “Today’s numbers are a 26% increase since yesterday. Over the course of the last week, there have been nearly 7,000 new cases reported. This tells us the virus is continuing to spread rapidly in China. The reported deaths have continued to rise as well. In addition, locations outside China have continued to report cases. There have been an increasing number of reports of person-to-person spread, and now, most recently, a report in the New England Journal of Medicine of asymptomatic spread.”

The quarantine of passengers will last 14 days from when the plane left Wuhan, China. Martin Cetron, MD, who directs the CDC’s Division of Global Migration and Quarantine, said that the quarantine order “offers the greatest level of protection for the American public in preventing introduction and spread. That is our primary concern. Prior epidemics suggest that when people are properly informed, they’re usually very compliant with this request to restrict their movement. This allows someone who would become symptomatic to be rapidly identified. Offering early, rapid diagnosis of their illness could alleviate a lot of anxiety and uncertainty. In addition, this is a protective effect on family members. No individual wants to be the source of introducing or exposing a family member or a loved one to their virus. Additionally, this is part of their civic responsibility to protect their communities.”

[email protected]

* This story was updated on 01/31/2020. 

The federal government declared a formal public health emergency on Jan. 31 to aid in the response to the 2019 Novel Coronavirus (2019-nCoV). The declaration, issued by Health and Human Services Secretary Alex. M. Azar II gives state, tribal, and local health departments additional flexibility to request assistance from the federal government in responding to the coronavirus.

"While this virus poses a serious public health threat, the risk to the American public remains low at this time, and we are working to keep this risk low."*

The government also began a quarantine of travelers. The 195 passengers who arrived at March Air Reserve Base in Ontario, Calif., from Wuhan, China on Jan. 29 are under federal quarantine amid growing concerns about the 2019-nCoV—the first such action taken by the Centers for Disease Control and Prevention in more than 50 years.

“This decision is based on the current scientific facts,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during a press briefing Jan. 31. “While we understand the action seems drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for over-reacting than under-reacting.”

These actions come on the heels of the World Health Organization’s Jan. 30 declaration of 2019-nCoV as a public health emergency of international concern, and from a recent spike in cases reported by Chinese health officials. “Every day this week China has reported additional cases,” Dr. Messonnier said. “Today’s numbers are a 26% increase since yesterday. Over the course of the last week, there have been nearly 7,000 new cases reported. This tells us the virus is continuing to spread rapidly in China. The reported deaths have continued to rise as well. In addition, locations outside China have continued to report cases. There have been an increasing number of reports of person-to-person spread, and now, most recently, a report in the New England Journal of Medicine of asymptomatic spread.”

The quarantine of passengers will last 14 days from when the plane left Wuhan, China. Martin Cetron, MD, who directs the CDC’s Division of Global Migration and Quarantine, said that the quarantine order “offers the greatest level of protection for the American public in preventing introduction and spread. That is our primary concern. Prior epidemics suggest that when people are properly informed, they’re usually very compliant with this request to restrict their movement. This allows someone who would become symptomatic to be rapidly identified. Offering early, rapid diagnosis of their illness could alleviate a lot of anxiety and uncertainty. In addition, this is a protective effect on family members. No individual wants to be the source of introducing or exposing a family member or a loved one to their virus. Additionally, this is part of their civic responsibility to protect their communities.”

[email protected]

* This story was updated on 01/31/2020. 

The federal government declared a formal public health emergency on Jan. 31 to aid in the response to the 2019 Novel Coronavirus (2019-nCoV). The declaration, issued by Health and Human Services Secretary Alex. M. Azar II gives state, tribal, and local health departments additional flexibility to request assistance from the federal government in responding to the coronavirus.

"While this virus poses a serious public health threat, the risk to the American public remains low at this time, and we are working to keep this risk low."*

The government also began a quarantine of travelers. The 195 passengers who arrived at March Air Reserve Base in Ontario, Calif., from Wuhan, China on Jan. 29 are under federal quarantine amid growing concerns about the 2019-nCoV—the first such action taken by the Centers for Disease Control and Prevention in more than 50 years.

“This decision is based on the current scientific facts,” Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said during a press briefing Jan. 31. “While we understand the action seems drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for over-reacting than under-reacting.”

These actions come on the heels of the World Health Organization’s Jan. 30 declaration of 2019-nCoV as a public health emergency of international concern, and from a recent spike in cases reported by Chinese health officials. “Every day this week China has reported additional cases,” Dr. Messonnier said. “Today’s numbers are a 26% increase since yesterday. Over the course of the last week, there have been nearly 7,000 new cases reported. This tells us the virus is continuing to spread rapidly in China. The reported deaths have continued to rise as well. In addition, locations outside China have continued to report cases. There have been an increasing number of reports of person-to-person spread, and now, most recently, a report in the New England Journal of Medicine of asymptomatic spread.”

The quarantine of passengers will last 14 days from when the plane left Wuhan, China. Martin Cetron, MD, who directs the CDC’s Division of Global Migration and Quarantine, said that the quarantine order “offers the greatest level of protection for the American public in preventing introduction and spread. That is our primary concern. Prior epidemics suggest that when people are properly informed, they’re usually very compliant with this request to restrict their movement. This allows someone who would become symptomatic to be rapidly identified. Offering early, rapid diagnosis of their illness could alleviate a lot of anxiety and uncertainty. In addition, this is a protective effect on family members. No individual wants to be the source of introducing or exposing a family member or a loved one to their virus. Additionally, this is part of their civic responsibility to protect their communities.”

[email protected]

* This story was updated on 01/31/2020. 

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

A number of years ago, a patient I was treating mentioned that she was not eating tomatoes. There had been stories in the news about people contracting bacterial infections from tomatoes, but I paused for a moment, then asked her: “Have there been any contaminated tomatoes here in Maryland?” There had not been and I was still happily eating salsa, but my patient thought about this differently: If disease-causing tomatoes were to come to our state, someone would be the first person to become ill. She did not want to take any risks. My patient, however, was a heavy smoker and already grappling with health issues that were caused by smoking, so I found her choice of what she should worry about and how it influenced her behavior to be perplexing. I realize it’s not the same; nicotine is an addiction, while tomatoes remain a choice for most of us, and it’s common for people to worry about very unlikely events even when we are surrounded by very real and statistically more probable threats to our well-being.

Today’s news reports are filled with stories about 2019 Novel Coronavirus (2019-nCoV), an illness that started in Wuhan, China; as of Jan. 31, 2020, there were 9,776 confirmed cases and 213 deaths. There have been an additional 118 cases reported outside of mainland China, including 6 in the United States, and no one outside of China has died.

The response to the virus has been remarkable: Wuhan, a city of more than 11 million inhabitants, is on lockdown, as are 15 other cities in China; 46 million people have been affected, the largest quarantine in human history. Travel is restricted in parts of China, airports all over the world are screening those who fly in from Wuhan, foreign governments are bringing their citizens home from Wuhan, and even Starbucks has temporarily closed half its stores in China. The economics of containing this virus are astounding.

In the meantime, the Centers for Disease Control and Prevention reports that, as of the week of Jan. 25, there have been 19 million cases of the flu in the United States. Of those stricken, 180,000 people have been hospitalized and 10,000 have died, including 68 pediatric patients. No cities are on lockdown, public transportation runs as usual, airports don’t screen passengers for flu symptoms, and Starbucks continues to serve vanilla lattes to any willing customer. Anxiety about illness is not new; we’ve seen it with SARS, Ebola, measles, and even around Chipotle’s food poisoning cases – to name just a few recent scares. We have also seen a lot of media on vaping-related deaths, and as of early January 2020, vaping-related illnesses affected 2,602 people with 59 deaths. It has been a topic of discussion among legislators, with an emphasis on either outlawing the flavoring that might appeal to younger people or simply outlawing e-cigarettes. No one, however, is talking about outlawing regular cigarettes, despite the fact that many people have switched from cigarettes to vaping products as a way to quit smoking. So, while vaping has caused 59 deaths since 2018, cigarettes are responsible for 480,000 fatalities a year in the United States and smokers live, on average, 10 years less than nonsmokers.

So what fuels anxiety about the latest health scare, and why aren’t we more anxious about the more common causes of premature mortality? Certainly, the newness and the unknown are factors in the coronavirus scare. It’s not certain how this illness was introduced into the human population, although one theory is that it started with the consumption of bats who carry the virus. It’s spreading fast, and in some people, it has been lethal. The incubation period is not known, or whether it is contagious before symptoms appear. Coronavirus is getting a lot of public health attention and the World Health Organization just announced that the virus is a public health emergency of international concern. On the televised news on Jan. 29, 2020, coronavirus was the top story in the United States, even though an impeachment trial is in progress for our country’s president.

The public health response of locking down cities may help contain the outbreak and prevent a global epidemic, although millions of people had already left Wuhan, so the heavy-handed attempt to prevent spread of the virus may well be too late. In the case of the Ebola virus – a much more lethal disease that was also thought to be introduced by bats – public health measures certainly curtailed global spread, and the epidemic of 2014-2016 was limited to 28,600 cases and 11,325 deaths, nearly all of them in West Africa.

Most of the things that cause people to die are not new and are not topics the media chooses to sensationalize. Dissemination of news has changed over the decades, with so much more of it, instant reports on social media, and competition for viewers that leads journalists to pull at our emotions. We might worry about getting food poisoning from romaine lettuce – if that is what the news is focusing on – but we don’t worry when we enter our cars, keep firearms in our homes, or light up cigarettes. And while we may, or may not, get flu shots and avoid those who have the flu, how and where we position both our anxiety and our resources does not always make sense. Certainly some people are predisposed to worry about both common and uncommon dangers, while others seem never to worry and engage in acts that many of us would consider dangerous. If we are looking for logic, it may be hard to find – there are those who would happily go bungee jumping but wouldn’t dream of leaving the house out without hand sanitizer.

The repercussions from this massive response to the Wuhan coronavirus are significant. For the millions of people on lockdown in China, each day gets emotionally harder; some may begin to have issues procuring food, and the financial losses for the economy will be significant. It’s not really possible to know yet if this response is warranted; we do know that infectious diseases can kill millions. The AIDS pandemic has taken the lives of 36 million people since 1981, and the influenza pandemic of 1918 resulted in an estimated 20 million to 50 million deaths after infecting 500 million people. Still, one might wonder if other, more mundane causes of morbidity and mortality – the ones that no longer garner our dread or make it to the front pages – might also be worthy of more hype and resources.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

In hospital medicine, inpatients often request more freedom to move within the hospital complex for a wide range of both benign and potentially concerning reasons, says Sara Stream, MD.

thinkstockphotos.com

“Hospitalists are often confronted with a dilemma when considering these patient requests: how to promote patient-centered care and autonomy while balancing patient safety, concerns for hospital liability, and the delivery of timely, efficient medical care,” said Dr. Stream, a hospitalist at the VA New York Harbor Healthcare System. Guidance from medical literature and institutional policies on inpatient movement are lacking, so Dr. Stream coauthored an article seeking to develop a framework with which hospitalists can approach patient requests for liberalized movement.

The authors concluded that for a small subset of patients, liberalized movement within the hospital may be clinically feasible: those who are medically, physically, and psychiatrically stable enough to move off their assigned floors without inordinate risk. “For the rest of inpatients, movement outside their monitored inpatient settings may interfere with appropriate medical care and undermine the indications for acute hospitalization,” Dr. Stream said.

Creating institutional policy that identifies relevant clinical, legal and ethical considerations, while incorporating the varied perspectives of physicians, patients, nurses, and hospital administration/risk management will allow requests for increased movement to be evaluated systematically and transparently.

“When patients request liberalized movement, hospitalists should consider the requests systematically: first to identify the intent behind requests, and then to follow a framework to determine whether increased movement would be safe and allow appropriate medical care without creating additional risks,” Dr. Stream said.

Hospitalists should assess and compile individual patient requests for liberalized movement and work with other physicians, nurses, hospital administration, and risk management to devise pertinent policy on this issue that is specific to their institutions. “By eventually creating clear guidelines in policy, health care providers will spend less time managing each individual request to leave the floor because they have a systematic strategy for making consistent decisions about patient movement,” the authors concluded.

Reference

1. Stream S, Alfandre D. “Just Getting a Cup of Coffee” – Considering Best Practices for Patients’ Movement off the Hospital Floor. J Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227.

Trends in opioid prescribing and use from 2010 to 2016 offer some encouragement, but opioid-attributable deaths continued to increase over that period, according to the Centers for Disease Control and Prevention.

Prescribing rates dropped during that period, as did daily opioid dosage rates and the percentage of patients with high daily opioid dosages, Gail K. Strickler, PhD, of the Institute for Behavioral Health at Brandeis University in Waltham, Mass., and associates wrote in MMWR Surveillance Summaries.

Their analysis involved 11 of the 12 states (Washington was unable to provide data for the analysis) participating in the CDC’s Prescription Behavior Surveillance System, which uses data from the states’ prescription drug monitoring programs. The 11 states represented about 38% of the U.S. population in 2016.

The opioid prescribing rate fell in 10 of those 11 states, with declines varying from 3.4% in Idaho to 33.0% in Ohio. Prescribing went up in Texas by 11.3%, but the state only had data available for 2015 and 2016. Three other states – Delaware, Florida, and Idaho – were limited to data from 2012 to 2016, the investigators noted.

As for the other measures, all states showed declines for the mean daily opioid dosage. Texas had the smallest drop at 2.9% and Florida saw the largest, at 27.4%. All states also had reductions in the percentage of patients with high daily opioid dosage, with decreases varying from 5.7% in Idaho to 43.9% in Louisiana, Dr. Strickler and associates reported. A high daily dosage was defined as at least 90 morphine milligram equivalents for all class II-V opioid drugs.

“Despite these favorable trends ... opioid overdose deaths attributable to the most commonly prescribed opioids, the natural and semisynthetics (e.g., morphine and oxycodone), increased during 2010-2016,” they said.

It is possible that a change in mortality is lagging “behind changes in prescribing behaviors” or that “the trend in deaths related to these types of opioids has been driven by factors other than prescription opioid misuse rates, such as increasing mortality from heroin, which is frequently classified as morphine or found concomitantly with morphine postmortem, and a spike in deaths involving illicitly manufactured fentanyl combined with heroin and prescribed opioids since 2013,” the investigators suggested.

[email protected]

SOURCE: Strickler GK et al. MMWR Surveill Summ. 2020 Jan 31;69(1):1-14.

Trends in opioid prescribing and use from 2010 to 2016 offer some encouragement, but opioid-attributable deaths continued to increase over that period, according to the Centers for Disease Control and Prevention.

Prescribing rates dropped during that period, as did daily opioid dosage rates and the percentage of patients with high daily opioid dosages, Gail K. Strickler, PhD, of the Institute for Behavioral Health at Brandeis University in Waltham, Mass., and associates wrote in MMWR Surveillance Summaries.

Their analysis involved 11 of the 12 states (Washington was unable to provide data for the analysis) participating in the CDC’s Prescription Behavior Surveillance System, which uses data from the states’ prescription drug monitoring programs. The 11 states represented about 38% of the U.S. population in 2016.

The opioid prescribing rate fell in 10 of those 11 states, with declines varying from 3.4% in Idaho to 33.0% in Ohio. Prescribing went up in Texas by 11.3%, but the state only had data available for 2015 and 2016. Three other states – Delaware, Florida, and Idaho – were limited to data from 2012 to 2016, the investigators noted.

As for the other measures, all states showed declines for the mean daily opioid dosage. Texas had the smallest drop at 2.9% and Florida saw the largest, at 27.4%. All states also had reductions in the percentage of patients with high daily opioid dosage, with decreases varying from 5.7% in Idaho to 43.9% in Louisiana, Dr. Strickler and associates reported. A high daily dosage was defined as at least 90 morphine milligram equivalents for all class II-V opioid drugs.

“Despite these favorable trends ... opioid overdose deaths attributable to the most commonly prescribed opioids, the natural and semisynthetics (e.g., morphine and oxycodone), increased during 2010-2016,” they said.

It is possible that a change in mortality is lagging “behind changes in prescribing behaviors” or that “the trend in deaths related to these types of opioids has been driven by factors other than prescription opioid misuse rates, such as increasing mortality from heroin, which is frequently classified as morphine or found concomitantly with morphine postmortem, and a spike in deaths involving illicitly manufactured fentanyl combined with heroin and prescribed opioids since 2013,” the investigators suggested.

[email protected]

SOURCE: Strickler GK et al. MMWR Surveill Summ. 2020 Jan 31;69(1):1-14.

Trends in opioid prescribing and use from 2010 to 2016 offer some encouragement, but opioid-attributable deaths continued to increase over that period, according to the Centers for Disease Control and Prevention.

Prescribing rates dropped during that period, as did daily opioid dosage rates and the percentage of patients with high daily opioid dosages, Gail K. Strickler, PhD, of the Institute for Behavioral Health at Brandeis University in Waltham, Mass., and associates wrote in MMWR Surveillance Summaries.

Their analysis involved 11 of the 12 states (Washington was unable to provide data for the analysis) participating in the CDC’s Prescription Behavior Surveillance System, which uses data from the states’ prescription drug monitoring programs. The 11 states represented about 38% of the U.S. population in 2016.

The opioid prescribing rate fell in 10 of those 11 states, with declines varying from 3.4% in Idaho to 33.0% in Ohio. Prescribing went up in Texas by 11.3%, but the state only had data available for 2015 and 2016. Three other states – Delaware, Florida, and Idaho – were limited to data from 2012 to 2016, the investigators noted.

As for the other measures, all states showed declines for the mean daily opioid dosage. Texas had the smallest drop at 2.9% and Florida saw the largest, at 27.4%. All states also had reductions in the percentage of patients with high daily opioid dosage, with decreases varying from 5.7% in Idaho to 43.9% in Louisiana, Dr. Strickler and associates reported. A high daily dosage was defined as at least 90 morphine milligram equivalents for all class II-V opioid drugs.

“Despite these favorable trends ... opioid overdose deaths attributable to the most commonly prescribed opioids, the natural and semisynthetics (e.g., morphine and oxycodone), increased during 2010-2016,” they said.

It is possible that a change in mortality is lagging “behind changes in prescribing behaviors” or that “the trend in deaths related to these types of opioids has been driven by factors other than prescription opioid misuse rates, such as increasing mortality from heroin, which is frequently classified as morphine or found concomitantly with morphine postmortem, and a spike in deaths involving illicitly manufactured fentanyl combined with heroin and prescribed opioids since 2013,” the investigators suggested.

[email protected]

SOURCE: Strickler GK et al. MMWR Surveill Summ. 2020 Jan 31;69(1):1-14.

ORLANDO – Because Food and Drug Administration–approved treatment options for children and adolescents with severe dermatologic diseases are limited, systemic therapies for these patients often require the use of off-label medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.

Jeff Craven/MDedge News

“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.

Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.

Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.

Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.

While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.

The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”

In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.

Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.

“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”

In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.

When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.

She reported having no conflicts of interest.

ORLANDO – Because Food and Drug Administration–approved treatment options for children and adolescents with severe dermatologic diseases are limited, systemic therapies for these patients often require the use of off-label medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.

Jeff Craven/MDedge News

“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.

Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.

Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.

Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.

While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.

The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”

In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.

Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.

“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”

In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.

When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.

She reported having no conflicts of interest.

ORLANDO – Because Food and Drug Administration–approved treatment options for children and adolescents with severe dermatologic diseases are limited, systemic therapies for these patients often require the use of off-label medications. However, this scenario is changing, A. Yasmine Kirkorian, MD, said at the ODAC Dermatology, Aesthetic & Surgical Conference.

Jeff Craven/MDedge News

“I really would like to emphasize that children with severe disease need to be treated,” added Dr. Kirkorian, a pediatric dermatologist at George Washington University, Washington, and Children’s National Health System, where she is interim chief of the division of dermatology.

Current on-label systemic therapies for pediatric skin disease include etanercept for psoriasis (4 years and older), ustekinumab for psoriasis (12 years and older), adalimumab for hidradenitis suppurativa (12 years and older), and omalizumab for chronic idiopathic urticaria (12 years and older). A new addition to the list is dupilumab, which was approved for children and adolescents with atopic dermatitis (AD) aged 12 years and older in 2019, she noted.

Dupilumab is currently being studied in children aged 6 months to 12 years, and other clinical trials are evaluating more options for pediatric patients with AD, alopecia areata, and psoriasis. They include a clinical trial of the oral Janus kinase 3 (JAK3) inhibitor PF-06651600 in patients aged 12 years and older with alopecia areata. Six biologic therapies are being evaluated for psoriasis in patients beginning at 6 years: ixekizumab, secukinumab, ustekinumab, guselkumab, brodalumab, and apremilast.

Some systemic therapies are off-label “but used all the time” for dermatologic diseases in pediatrics, Dr. Kirkorian noted. One example is methotrexate, which is approved by the FDA for acute lymphoblastic leukemia, meningeal leukemia, and juvenile idiopathic arthritis down to infancy. Having existing efficacy and safety data for a medication in a pediatric population, even for a different disease, can be helpful when counseling parents of children with severe dermatologic disease. “If you have something, even in an older population of children, it can be reassuring, or you can use evidence from other diseases,” she said.

While methotrexate is a cheap option and approved by the FDA for other pediatric indications down to infancy, the cons of using it to treat AD in pediatric patients are numerous. Treatment requires a number of blood draws for lab testing, which can be discouraging for younger patients, and the reported adverse effect profile may be concerning to some parents, while “in practice doesn’t really occur,” she said. Methotrexate is a teratogen so is not appropriate for teenagers who are sexually active and not using contraception.

The “biggest problem,” though, is the issue of whether methotrexate is effective, since it doesn’t always work for AD, Dr. Kirkorian said. “Even at the highest doses, I often feel that we fail the atopic children,” as opposed to using it to treat psoriasis, “where you know I’m going to get you on something that works.”

In contrast, cyclosporine is FDA approved down to infancy, and works quickly as a bridge to other therapy, and is not expensive, Dr. Kirkorian said. Cons include the need for blood draws, blood pressure checks, drug interactions, and adverse effects, she noted, adding that she tries to use cyclosporine as a bridge to on-label and off-label dupilumab.

Even with FDA approval for dupilumab down to age 12 years, she said it can be difficult to get insurance approval for the on-label treatment for patients in this age group with AD, before they first fail other therapies (even with off-label systemic drugs). For patients under age 12 years, getting approval is even more challenging and requires rigorous documentation of what therapies the child has failed, and how it has affected their quality of life, she said.

“If you send in a letter to the insurance company without an IGA [Investigator Global Assessment] or SCORAD, you’re going to get rejected,” Dr. Kirkorian said. In addition to those two measures, she provides “everything else,” including the impact of the disease on quality of life of patients, and school, she said, adding, “Did they miss school, did they get hospitalized for infections? And do they have comorbid diseases that might help you get approval?”

In pediatric patients with psoriasis, common issues are more likely to be about how insurance dictates step therapy. She has often found that young children may stop responding to etanercept after a few years, which can justify a switch to ustekinumab or a new treatment in a clinical trial, she said. Adolescents with psoriasis can receive ustekinumab, which is approved for psoriasis in patients aged 12-17 years, she said, noting that the infrequent ustekinumab dosing schedule is often beneficial in this population.

When all other approved options fail for young patients with psoriasis, justifying off-label use isn’t always easy. “You just have to make a justification based on the literature, even though it’s off label,” citing available safety information for other diseases, and “demonstrate over and over the impact on quality of life,” which works “most of the time,” Dr. Kirkorian said.

She reported having no conflicts of interest.

Diabetes is a complex disease with a range of nuanced therapy options and a plethora of risk factors that could significantly affect patient quality of life and long-term outcomes. From the outset, after diagnosis, a selected regimen has to be meticulously tailored to a patient’s clinical needs and monitored over time, and many other nonclinical variables, such as patient preference, social history, access to care, and support systems, as well as the cost of the drugs and its impact on the patient, must also be considered.

The increase in the incidence of youth-onset diabetes means that more young adults are making the transition from pediatric to adult care, and careful care coordination is paramount at the handover point to ensure that a full and complete account of the history gets transferred to the adult-care provider.

So how do you distill the information from all those records (on paper and online) that you’ve accumulated during the time you’ve been treating a young adult who is now transitioning to adult care?
 

Transition summary

One resource that can facilitate this handover is the transition summary. It effectively consolidates and packages the aforementioned aspects of care and patient history so that the adult-care provider does not have to collect the patient’s history from the start. The transition summary should not be confused with the discharge or medical summary, which focuses only on the preceding clinical care.

It is important to stress at this stage that collaboration between the pediatric- and adult-care providers is crucial to the success of such a summary, from its creation, to its implementation, and through the subsequent and inevitable revisions and updates.
 

Benefits all around

After we introduced the transition summary at my institution, we found that the average initial patient visit with the new adult-care provider decreased by 12 minutes (with a range of 6-19 min). The adult-care providers welcomed receiving such detailed, important patient information packaged in a concise and readily accessible format. It helped them identify the preceding care team members, which facilitated continuity of care, and it also helped them forge a better therapeutic relationship with the patient earlier on in their engagement.

We also learned that patients were more comfortable with the transition, and the referring providers were relieved and reassured that their patients would continue to receive personalized care with the new adult-care provider.

At a personal level, I found I was less stressed as I could spend better-quality clinical time with patients. And I got to eliminate those unwieldy stacks of medical records since getting buy-in from divisional and IT leadership enabled us to automate the entire process of information transfer.

It is important to note that the patient has to consent to release of medical records to other institutions.
 

Setting up the summary

At our clinic, I started out by adapting the transition summary from guidelines provided by the Endocrine Society to make a template. Then, in collaboration with my pediatric colleagues, I removed and added information so that the revised document would contain information that is vitally important and not readily available in the chart and would be feasible to fill out. For example, we included details such as the patient’s psychosocial history, an estimation of the patient barriers to diabetes management, family relationship issues, and the patient’s reasons for not adopting advanced diabetes technology (see accompanying example of a transition summary) .

I kept the summary brief, at two pages, and piloted it with referring providers who were interested in using the summary and with related supporting services. I also sought buy-in from my institution. This meant that I needed pediatric and adult divisional leadership support, which offered me information technology, resources, and expertise to automate the summary within the electronic health record. Once I had feedback from would-be users, we revised and updated the summary. We set up training for staff, including pediatric providers, nurse practitioners, social workers, and nurses who could fill out the summary, and ultimately succeeded in making it mandatory that the adult-care provider receive a summary before scheduling or seeing the transfer patient.

I started out with a paper version, and once we’d refined the questions, we incorporated it into the electronic medical record.

The information we use in our summary is grouped under the following headings:

• Reason for transition.
• Diabetes type.
• Degree of diabetes control.
• Type of insulin therapy and supplies.
• Current and former insulin regimen: reasons for discontinuation of any therapies or reluctance to start any therapies.
• Diabetes health maintenance.
• Social history and support, including living situation, main social support network, child protective services involvement.
• Other pertinent medical surgical history, including psychiatric disease.

Tips and takeaways

Top of the list of takeaways is that you should make the final document work for you, your colleagues, and ultimately, your patients – customize it as you see fit, but be sure to keep it short and easy to fill out. Make a note as you start using it in practice of what you think might be missing from the chart and whether updates are needed. If you can, it’s a great idea to fold the transfer summary into the electronic medical record, though it’s not imperative. Care coordination is key to successful transfer of patients, whether from pediatric to adult care or hospital to home. A small change to work flow can result in a huge change in patient and provider satisfaction, as well as a reduction in visit times.
 

Dr. Agarwal is director of the Supporting Emerging Adults With Diabetes (SEAD) program at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine, New York. She reports no disclosures or financial conflicts of interest. Write to her at [email protected].

Diabetes is a complex disease with a range of nuanced therapy options and a plethora of risk factors that could significantly affect patient quality of life and long-term outcomes. From the outset, after diagnosis, a selected regimen has to be meticulously tailored to a patient’s clinical needs and monitored over time, and many other nonclinical variables, such as patient preference, social history, access to care, and support systems, as well as the cost of the drugs and its impact on the patient, must also be considered.

The increase in the incidence of youth-onset diabetes means that more young adults are making the transition from pediatric to adult care, and careful care coordination is paramount at the handover point to ensure that a full and complete account of the history gets transferred to the adult-care provider.

So how do you distill the information from all those records (on paper and online) that you’ve accumulated during the time you’ve been treating a young adult who is now transitioning to adult care?
 

Transition summary

One resource that can facilitate this handover is the transition summary. It effectively consolidates and packages the aforementioned aspects of care and patient history so that the adult-care provider does not have to collect the patient’s history from the start. The transition summary should not be confused with the discharge or medical summary, which focuses only on the preceding clinical care.

It is important to stress at this stage that collaboration between the pediatric- and adult-care providers is crucial to the success of such a summary, from its creation, to its implementation, and through the subsequent and inevitable revisions and updates.
 

Benefits all around

After we introduced the transition summary at my institution, we found that the average initial patient visit with the new adult-care provider decreased by 12 minutes (with a range of 6-19 min). The adult-care providers welcomed receiving such detailed, important patient information packaged in a concise and readily accessible format. It helped them identify the preceding care team members, which facilitated continuity of care, and it also helped them forge a better therapeutic relationship with the patient earlier on in their engagement.

We also learned that patients were more comfortable with the transition, and the referring providers were relieved and reassured that their patients would continue to receive personalized care with the new adult-care provider.

At a personal level, I found I was less stressed as I could spend better-quality clinical time with patients. And I got to eliminate those unwieldy stacks of medical records since getting buy-in from divisional and IT leadership enabled us to automate the entire process of information transfer.

It is important to note that the patient has to consent to release of medical records to other institutions.
 

Setting up the summary

At our clinic, I started out by adapting the transition summary from guidelines provided by the Endocrine Society to make a template. Then, in collaboration with my pediatric colleagues, I removed and added information so that the revised document would contain information that is vitally important and not readily available in the chart and would be feasible to fill out. For example, we included details such as the patient’s psychosocial history, an estimation of the patient barriers to diabetes management, family relationship issues, and the patient’s reasons for not adopting advanced diabetes technology (see accompanying example of a transition summary) .

I kept the summary brief, at two pages, and piloted it with referring providers who were interested in using the summary and with related supporting services. I also sought buy-in from my institution. This meant that I needed pediatric and adult divisional leadership support, which offered me information technology, resources, and expertise to automate the summary within the electronic health record. Once I had feedback from would-be users, we revised and updated the summary. We set up training for staff, including pediatric providers, nurse practitioners, social workers, and nurses who could fill out the summary, and ultimately succeeded in making it mandatory that the adult-care provider receive a summary before scheduling or seeing the transfer patient.

I started out with a paper version, and once we’d refined the questions, we incorporated it into the electronic medical record.

The information we use in our summary is grouped under the following headings:

• Reason for transition.
• Diabetes type.
• Degree of diabetes control.
• Type of insulin therapy and supplies.
• Current and former insulin regimen: reasons for discontinuation of any therapies or reluctance to start any therapies.
• Diabetes health maintenance.
• Social history and support, including living situation, main social support network, child protective services involvement.
• Other pertinent medical surgical history, including psychiatric disease.

Tips and takeaways

Top of the list of takeaways is that you should make the final document work for you, your colleagues, and ultimately, your patients – customize it as you see fit, but be sure to keep it short and easy to fill out. Make a note as you start using it in practice of what you think might be missing from the chart and whether updates are needed. If you can, it’s a great idea to fold the transfer summary into the electronic medical record, though it’s not imperative. Care coordination is key to successful transfer of patients, whether from pediatric to adult care or hospital to home. A small change to work flow can result in a huge change in patient and provider satisfaction, as well as a reduction in visit times.
 

Dr. Agarwal is director of the Supporting Emerging Adults With Diabetes (SEAD) program at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine, New York. She reports no disclosures or financial conflicts of interest. Write to her at [email protected].

Diabetes is a complex disease with a range of nuanced therapy options and a plethora of risk factors that could significantly affect patient quality of life and long-term outcomes. From the outset, after diagnosis, a selected regimen has to be meticulously tailored to a patient’s clinical needs and monitored over time, and many other nonclinical variables, such as patient preference, social history, access to care, and support systems, as well as the cost of the drugs and its impact on the patient, must also be considered.

The increase in the incidence of youth-onset diabetes means that more young adults are making the transition from pediatric to adult care, and careful care coordination is paramount at the handover point to ensure that a full and complete account of the history gets transferred to the adult-care provider.

So how do you distill the information from all those records (on paper and online) that you’ve accumulated during the time you’ve been treating a young adult who is now transitioning to adult care?
 

Transition summary

One resource that can facilitate this handover is the transition summary. It effectively consolidates and packages the aforementioned aspects of care and patient history so that the adult-care provider does not have to collect the patient’s history from the start. The transition summary should not be confused with the discharge or medical summary, which focuses only on the preceding clinical care.

It is important to stress at this stage that collaboration between the pediatric- and adult-care providers is crucial to the success of such a summary, from its creation, to its implementation, and through the subsequent and inevitable revisions and updates.
 

Benefits all around

After we introduced the transition summary at my institution, we found that the average initial patient visit with the new adult-care provider decreased by 12 minutes (with a range of 6-19 min). The adult-care providers welcomed receiving such detailed, important patient information packaged in a concise and readily accessible format. It helped them identify the preceding care team members, which facilitated continuity of care, and it also helped them forge a better therapeutic relationship with the patient earlier on in their engagement.

We also learned that patients were more comfortable with the transition, and the referring providers were relieved and reassured that their patients would continue to receive personalized care with the new adult-care provider.

At a personal level, I found I was less stressed as I could spend better-quality clinical time with patients. And I got to eliminate those unwieldy stacks of medical records since getting buy-in from divisional and IT leadership enabled us to automate the entire process of information transfer.

It is important to note that the patient has to consent to release of medical records to other institutions.
 

Setting up the summary

At our clinic, I started out by adapting the transition summary from guidelines provided by the Endocrine Society to make a template. Then, in collaboration with my pediatric colleagues, I removed and added information so that the revised document would contain information that is vitally important and not readily available in the chart and would be feasible to fill out. For example, we included details such as the patient’s psychosocial history, an estimation of the patient barriers to diabetes management, family relationship issues, and the patient’s reasons for not adopting advanced diabetes technology (see accompanying example of a transition summary) .

I kept the summary brief, at two pages, and piloted it with referring providers who were interested in using the summary and with related supporting services. I also sought buy-in from my institution. This meant that I needed pediatric and adult divisional leadership support, which offered me information technology, resources, and expertise to automate the summary within the electronic health record. Once I had feedback from would-be users, we revised and updated the summary. We set up training for staff, including pediatric providers, nurse practitioners, social workers, and nurses who could fill out the summary, and ultimately succeeded in making it mandatory that the adult-care provider receive a summary before scheduling or seeing the transfer patient.

I started out with a paper version, and once we’d refined the questions, we incorporated it into the electronic medical record.

The information we use in our summary is grouped under the following headings:

• Reason for transition.
• Diabetes type.
• Degree of diabetes control.
• Type of insulin therapy and supplies.
• Current and former insulin regimen: reasons for discontinuation of any therapies or reluctance to start any therapies.
• Diabetes health maintenance.
• Social history and support, including living situation, main social support network, child protective services involvement.
• Other pertinent medical surgical history, including psychiatric disease.

Tips and takeaways

Top of the list of takeaways is that you should make the final document work for you, your colleagues, and ultimately, your patients – customize it as you see fit, but be sure to keep it short and easy to fill out. Make a note as you start using it in practice of what you think might be missing from the chart and whether updates are needed. If you can, it’s a great idea to fold the transfer summary into the electronic medical record, though it’s not imperative. Care coordination is key to successful transfer of patients, whether from pediatric to adult care or hospital to home. A small change to work flow can result in a huge change in patient and provider satisfaction, as well as a reduction in visit times.
 

Dr. Agarwal is director of the Supporting Emerging Adults With Diabetes (SEAD) program at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine, New York. She reports no disclosures or financial conflicts of interest. Write to her at [email protected].

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Alzheimer disease and related dementias are a global health concern, affecting nearly 47 million people worldwide. Alzheimer disease and related dementias were among the top 10 causes of death worldwide in 2015 and are expected to increase by 10 million cases annually.¹ Despite the ethnic diversity of the US, there are considerable gaps in the literature regarding dementia and how it is diagnosed and treated among many ethnic and racial groups.

In 2012, President Barack Obama signed a declaration with the intention of decreasing ethnoracial disparities in Alzheimer disease research and treatment by increasing clinical care, research, and services targeted to racial and ethnic minorities.² Despite that declaration, in the US there are gaps in access to care for the geriatric population in general. The American Geriatrics Society estimates that the US has fewer than half the needed number of practicing geriatricians. In 2016, there was 1 geriatrician for every 1,924 Americans aged ≥ 65 years.³ Furthermore, health care providers (HCPs) are often not of the same ethnicity or adequately trained to assess and build relationships with ethnically and racially diverse populations.² Given the projected growth in the numbers of individuals worldwide with dementia, we have a responsibility to continue to develop strategies to provide more inclusive care.

By 2060, minority populations aged ≥ 65 years are expected to represent 45% of the US population, up from 22% in 2014.⁴ The growth of racial and ethnic minority groups are expected to exceed the growth of the non-Hispanic white population in the next few decades. By 2060, it is estimated that the US population will increase by 75% for non-Hispanic whites, 172% for African Americans, 270% for Asian and Pacific Islanders, 274% for American Indian and Alaska Natives, and 391% for Hispanics.⁴

A growing body of evidence suggests that Alzheimer disease and related dementias may disproportionately afflict minority groups in the US, which will become quite significant in the years ahead. The Alzheimer’s Association estimates that the prevalence of Alzheimer disease and other dementias among those aged > 65 years, is about twice the rate in African Americans and about 1.5 times the rate in Hispanics when compared with non-Hispanic whites.⁵ While increases in the incidence of Alzheimer disease and related dementias in non-Hispanic whites is expected to plateau around 2050, its incidence in ethnic and racial minority groups will continue to grow, especially among Hispanics.⁴ This stark realization provides additional compelling reasons for the US to develop preventative interventions or treatment options that may help delay the onset of the disease and to improve the quality of life of those with the disease or caregiving for those afflicted with it. Culturally competent care of these individuals is paramount.

Diagnosis

Early and accurate diagnosis of individuals with dementia confers many benefits, including early treatment; clinical trial participation; management of comorbid conditions; training, education, and support for patients and families; and legal, financial, and end of life care planning.³ Beyond the logistical concerns (such as HCP shortages), one of the challenges of assessing minority groups is finding staff who are culturally competent or speak the language necessary to accurately communicate and interact with these subgroups. Hispanics and African Americans often receive delayed or inadequate health care services or are diagnosed in an emergency department or other nontraditional setting.⁵

Even those individuals seeking or receiving care in primary care settings are not always forthcoming about their cognitive status. Only 56% of respondents in a recent survey of patients who had experienced subjective cognitive decline reported that they had discussed it with their HCP.⁴ This reticence is thought to be influenced by multiple factors, including distrust of the medical establishment, religious or spiritual beliefs, cultural or family beliefs and expectations about geriatric care, and lack of understanding about normal aging vs cognitive disorders. Furthermore, the sensitivity and specificity of current diagnostic tests for dementia have been questioned for nonwhite populations given the clinical presentation of dementia can vary across ethnoracial groups.⁵

As Luria noted, cognitive assessment tools developed and validated for use with one culture frequently results in experimental failures and are not valid for use with other cultural groups.¹ Cognitive testing results are influenced by educational and cultural factors, and this is one of the challenges in correctly diagnosing those of differing ethnoracial backgrounds. Individuals in racial and ethnic minorities may have limited formal education and/or high illiteracy rates and/or cultural nuances to problem solving, thinking, and memory that may not be reflected in current assessment tools.¹

There is hope that testing bias could be altered or eliminated using neuroimaging or biomarkers. However, the Alzheimer’s Disease Neuroimaging Initiative study of patients in the US and Canada included < 5% African American or Hispanic participants in its total sample. Few studies have systematically examined ethnoracial differences in amyloid positron emission tomography, and none have been published to date in ethnoracially diverse groups that assess the more recently developed tau imaging agents.¹

Diversity Among Caregivers

The research community must make greater efforts to improve recruitment of more diverse populations into clinical trials. Recent efforts by the National Institute on Aging in conjunction with the Alzheimer’s Association include developing a national strategy for clinical research recruitment and retention with an emphasis on local and diverse populations. This strategy should include various training modules, webinars, and similar educational opportunities for researchers and clinical HCPs, including HCPs from diverse ethnoracial backgrounds, to implement culturally appropriate research methodologies across these diverse groups. It is important that these educational materials be disseminated to caregivers in a way they can comprehend, as the impact on caregivers of those with Alzheimer disease and related dementias is considerable.

The US currently has 7 unpaid caregivers for every adult in the high-risk group of patients aged ≥ 65 years, but this will decline to a ratio of 4:1 by 2030.⁴ More than two-thirds of caregivers are non-Hispanic white, while 10% are African American, 8% are Hispanic, and 5% are Asian.³ About 34% of caregivers are themselves aged ≥ 65 years and are at risk for declines in their own health given the time and financial requirements of caring for someone else.³ In 2017, the 16.1 million family and other unpaid caregivers of people with dementia provided an estimated 18.4 billion hours of unpaid care, often resulting in considerable financial strain for these individuals. More than half of the caregivers report providing ≥ 21 hours of care per week; and 42% reported providing an average of 9 hours of care per day for people with dementia.

Caregivers report increased stress, sleep deprivation, depression and anxiety, and uncertainty in their ability to provide quality care to the individual with Alzheimer or a related dementia.³ The disproportionate prevalence of Alzheimer disease and other dementias in racially and ethnically diverse populations could further magnify already existing socioeconomic and other disparities and potentially lead to worsening of health outcomes in these groups.⁴ Given that minority populations tend to cluster geographically, community partnerships with local churches, senior centers, community centers, and other nontraditional settings may offer better opportunities for connecting with caregivers.

Conclusions

The growth and increasing diversity of the US older adult population in the coming decades require us as HCPs, researchers, and educators to dedicate more resources to ethnoracially diverse populations. There are still a great many unknowns about Alzheimer disease and dementia, most especially among nonwhites. Research, clinical care, and education must focus on outreach to marginalized groups so we may better be able to diagnose and treat the fastest growing older adult populations in the US. A complex combination of educational, cultural, social, and environmental factors likely contribute to delayed diagnosis and care of these groups, as well as lack of access to medical care, research venues, and trust issues between minority groups and the medical establishment. We all have an obligation to acknowledge these disparities and elicit the support of our colleagues and workplaces to raise awareness and dedicate necessary resources to this growing concern.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Dispensing of prescription stimulant medications, such as methylphenidate or amphetamine salts, has been expanding at a rapid rate over the past 2 decades. An astounding 58 million stimulant medications were prescribed in 2014.^1,2 Adults now exceed youths in the proportion of prescribed stimulant medications.^1,3

Off-label use of prescription stimulant medications, such as for performance enhancement, fatigue management, weight loss, medication-assisted therapy for stimulant use disorders, and adjunctive treatment for certain depressive disorders, is reported to be ≥ 40% of total stimulant use and is much more common in adults.¹ A 2017 study assessing risk of amphetamine use disorder and mortality among veterans prescribed stimulant medications within the Veterans Health Administration (VHA) reported off-label use in nearly 3 of every 5 incident users in 2012.⁴ Off-label use also is significantly more common when prescribed by nonpsychiatric physicians compared with that of psychiatrists.¹

One study assessing stimulant prescribing from 2006 to 2009 found that nearly 60% of adults were prescribed stimulant medications by nonpsychiatrist physicians, and only 34% of those adults prescribed a stimulant by a nonpsychiatrist physician had a diagnosis of attention-deficit hyperactivity disorder (ADHD).⁵ Findings from managed care plans covering years from 2000 to 2004 were similar, concluding that 30% of the adult patients who were prescribed methylphenidate had at least 1 medical claim with a diagnosis of ADHD.⁶ Of the approximately 16 million adults prescribed stimulant medications in 2017, > 5 million of them reported stimulant misuse.³ Much attention has been focused on misuse of stimulant medications by youths and young adults, but new information suggests that increased monitoring is needed among the US adult population. Per the US Department of Veterans Affairs (VA) Academic Detailing Stimulant Dashboard, as of October 2018 the national average of veterans with a documented substance use disorder (SUD) who are also prescribed stimulant medications through the VHA exceeds 20%, < 50% have an annual urine drug screen (UDS), and > 10% are coprescribed opioids and benzodiazepines.The percentage of veterans prescribed stimulant medications in the presence of a SUD has increased over the past decade, with a reported 8.7% incidence in 2002 increasing to 14.3% in 2012.⁴

There are currently no protocols, prescribing restrictions, or required monitoring parameters in place for prescription stimulant use within the Lexington VA Health Care System (LVAHCS). The purpose of this study was to evaluate the prescribing practices at LVAHCS of stimulant medications and identify opportunities for improvement in the prescribing and monitoring of this drug class.

Methods

This study was a single-center quality improvement project evaluating the prescribing practices of stimulant medications within LVAHCS and exempt from institutional review board approval. Veterans were included in the study if they were prescribed amphetamine salts, dextroamphetamine, lisdexamphetamine, or methylphenidate between January 1, 2018 and June 30, 2018; however, the veterans’ entire stimulant use history was assessed. Exclusion criteria included duration of use of < 2 months or < 2 prescriptions filled during the study period. Data for veterans who met the prespecified inclusion and exclusion criteria were collected via chart review and Microsoft SQL Server Management Studio.

Collected data included age, gender, stimulant regimen (drug name, dose, frequency), indication and duration of use, prescriber name and specialty, prescribing origin of initial stimulant medication, and whether stimulant use predated military service. Monitoring of stimulant medications was assessed via UDS at least annually, query of the prescription drug monitoring program (PDMP) at least quarterly, and average time between follow-up appointments with stimulant prescriber.

Monitoring parameters were assessed from January 1, 2017 through June 30, 2018, as it was felt that the 6-month study period would be too narrow to accurately assess monitoring trends. Mental health diagnoses, ADHD diagnostic testing if applicable, documented SUD or stimulant misuse past or present, and concomitant central nervous system (CNS) depressant use also were collected. CNS depressants evaluated were those that have abuse potential or significant psychotropic effects and included benzodiazepines, antipsychotics, opioids, gabapentin/pregabalin, Z-hypnotics, and muscle relaxants.

Results

The majority of participants were male (168/200) with an average age of 43.3 years. Dextroamphetamine/amphetamine was the most used stimulant (48.5%), followed by methylphenidate (40%), and dextroamphetamine (10%). Lisdexamphetamine was the least used stimulant, likely due to its formulary-restricted status within this facility. An extended release (ER) formulation was utilized in 1 of 4 participants, with 1 of 20 participants prescribed a combination of immediate release (IR) and ER formulations. Duration of use ranged from 3 months to 14 years, with an average duration of 4 years (Table 1).

Nearly 40% of participants reported an origin of stimulant initiation outside of LVAHCS. Fourteen percent of participants were started on prescription stimulant medications while active-duty service members. Stimulant medications were initiated at another VA facility in 10.5% of instances, and 15% of participants reported being prescribed stimulant medications by a civilian prescriber prior to receiving them at LVAHCS. Seventy-four of 79 (93.6%) participants with an origin of stimulant prescription outside of LVAHCS reported a US Federal Food and Drug Administration (FDA)-approved indication for use. The majority (87%) of stimulant medications were prescribed by the mental health service, and 25% of initial stimulant prescriptions were written by a single mental health prescriber. Eleven percent of participants were prescribed stimulant medications by multiple specialties, and nearly all participants had > 1 stimulant prescriber over the course of their treatment. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

Stimulant medications were used for FDA-approved indications (ADHD and narcolepsy) in 69.5% of participants. Note, this included patients who maintained an ADHD diagnosis in their medical record even if it was not substantiated with diagnostic testing. Of the participants reporting ADHD as an indication for stimulant use, diagnostic testing was conducted at LVAHCS to confirm an ADHD diagnosis in 58.6% (78/133) participants; 20.5% (16/78) of these diagnostic tests did not support the diagnosis of ADHD. All documented indications for use can be found in Table 2.

Discussion

The source of the initial stimulant prescription was assessed. The majority of veterans had received medical care prior to receiving care at LVAHCS, whether on active duty, from another VA facility throughout the country, or by a private civilian prescriber. The origin of initial stimulant medication and indication for stimulant medication use were patient reported. Requiring medical records from civilian providers prior to continuing stimulant medication is prescriber-dependent and was not available for all participants.

As expected, the majority of participants (87%) received their first stimulant prescription via a prescriber in the mental health specialty, 20 were prescribed stimulant medications from primary care, 4 from the emergency department (ED), and 2 from neurology. Three of the 4 stimulant prescriptions written in the ED were for continuity of care until the veteran could have an appointment with a mental health or primary care provider, and the other was prescribed by a mental health nurse practitioner for a veteran who presented to the ED with complaints of ADHD-like symptoms. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

The reasons for discontinuation included a positive UDS result for cocaine, psychosis, broken narcotic contract, ADHD diagnosis not supported by psychological testing, chronic bipolar disorder secondary to stimulant use, diversion, stimulant misuse, and lack of indication for use. There also were a handful of veterans whose VA prescribers declined to initiate prescription stimulant medications for various reasons, so the veteran sought care from a civilian prescriber who prescribed stimulant medications, then returned to the VA for medication management, and stimulant medications were continued. Fourteen percent (28/200) of participants had multiple indications for use at some point during stimulant medication therapy. Eight of those were a reasonable change from ADHD to ADHD-like symptoms when diagnosis was not substantiated by testing. The cause of other changes in indication for use was not well documented and often unclear. One veteran had 4 different indications for use documented in the medical record, often changing with each change in prescriber. It appeared that the most recent prescriber was uncertain of the actual indication for use but did not want to discontinue the medication. This prescriber documented that the stimulant medication should continue for presumed ADHD/mood/fatigue/cognitive dysfunction, which were all of the indications documented by the veteran’s previous prescribers.

Reasons for Discontinuation

ADHD was the most prominent indication for use, although the indication was changed to ADHD-like symptoms in several veterans for whom diagnostic testing did not support the ADHD diagnosis. Seventy-eight of 133 veterans prescribed stimulant medications for ADHD received diagnostic testing via a psychologist at LVAHCS. For the 11 veterans who had testing after stimulant initiation, a stimulant-free period was required prior to testing to ensure an accurate diagnosis. For 21% of veterans, the ADHD diagnosis was unsubstantiated by formal testing; however, all of these veterans continued stimulant medication use. For 1 veteran, the psychologist performing the testing documented new diagnoses, including moderate to severe stimulant use disorder and malingering both for PTSD and ADHD. The rate of stimulant prescribing inconsistency, “prescriber-hopping,” and unsupported ADHD diagnosis results warrant a conversation about expectations for transitions of care regarding stimulant medications, not only from outside to inside LVAHCS, but from prescriber to prescriber within the facility.

In some cases, stimulant medications were discontinued by a prescriber secondary to a worsening of another mental health condition. More than half of the participants in this study had an anxiety disorder diagnosis. Whether or not anxiety predated stimulant use or whether the use of stimulant medications contributed to the diagnosis and thus the addition of an additional CNS depressant to treat anxiety may be an area of research for future consideration. Although bipolar disorder, anxiety disorders, psychosis, and SUD are not contraindications for use of stimulant medications, caution must be used in patients with these diagnoses. Prescribers must weigh risks vs benefits as well as perform close monitoring during use. Similarly, one might look further into stimulant medications prescribed for fatigue and assess the role of any simultaneously prescribed CNS depressants. Is the stimulant being used to treat the adverse effect (AE) of another medication? In 2 documented instances in this study, a psychologist conducted diagnostic testing who reported that the veteran did not meet the criteria for ADHD but that a stimulant may help counteract the iatrogenic effect of anticonvulsants. In both instances stimulant use continued.

Prescription Monitoring

Polysubstance use disorder (5%) was the third most common SUD recorded among study participants. The majority of those with polysubstance use disorder reported abuse/misuse of illicit or prescribed stimulants. Stimulant abuse/misuse was documented in 25 of 200 (12.5%) study participants. In several instances, abuse/misuse was detected by the LVAHCS delivery coordination pharmacist who tracks patterns of early fill requests and prescriptions reported lost/stolen. This pharmacist may request that the prescriber obtain PDMP query, UDS, or pill count if concerning patterns are noted. Lisdexamphetamine is a formulary-restricted medication at LVAHCS, but it was noted to be approved for use when prescribers requested an abuse-deterrent formulation. Investigators noticed a trend in veterans whose prescriptions exceeded the recommended maximum dosage also having stimulant abuse/misuse documented in their medical record. The highest documented total daily dose in this study was 120-mg amphetamine salts IR for ADHD, compared with the normal recommended dosing range of 5 to 40 mg/d for the same indication.

Various modalities were used to monitor participants but less than half of veterans had an annual UDS, quarterly PDMP query, and quarterly prescriber follow-up. PDMP queries and prescriber follow-up was assessed quarterly as would be reasonable given that private sector practitioners may issue multiple prescriptions authorizing the patient to receive up to a 90-day supply.⁷ Prescriber follow-up ranged from 1 to 15 months. A longer time to follow-up was seen more frequently in stimulant medications prescribed by primary care as compared with that of mental health.

Clinical Practice Protocol

Data from this study were collected with the intent to identify opportunities for improvement in the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a facility-specific clinical practice protocol (CPP) for stimulant prescribing. It may also be beneficial to formulate a chronic stimulant management agreement between patient and prescriber to provide informed consent and clear expectations prior to stimulant medication initiation.

A CPP could be used to establish stimulant prescribing rules within a facility, which may limit who can prescribe stimulant medications or include a review process and/or required documentation in the medical record when being prescribed outside of specified dosing range and indications for use designated in the CPP or other evidence-based guidelines. Transition of care was found to be an area of opportunity in this study, which could be mitigated with the requirement of a baseline assessment prior to stimulant initiation with the expectation that it be completed regardless of prior prescription stimulant medication use. There was a lack of consistent monitoring for participants in this study, which may be improved if required monitoring parameters and frequency were provided for prescribers. For example, monitoring of heart rate and blood pressure was not assessed in this study, but a CPP may include monitoring vital signs before and after each dose change and every 6 months, per recommendation from the National Institute for Health and Care Excellence ADHD Diagnosis and Management guideline published in 2018.⁸The CPP may list the responsibilities of all those involved in the prescribing of stimulant medications, such as mental health service leadership, prescribers, nursing staff, pharmacists, social workers, psychologists, and other mental health staff. For prescribers this may include a thorough baseline assessment and criteria for use that must be met prior to stimulant initiation, documentation that must be included in the medical record and required monitoring during stimulant treatment, and expectations for increased monitoring and/or termination of treatment with nonadherence, diversion, or abuse/misuse.

The responsibilities of pharmacists may include establishing criteria for use of nonformulary and restricted agents as well as completion of nonformulary/restricted requests, reviewing dosages that exceed the recommended FDA daily maximum, reviewing uncommon off-label uses of stimulant medications, review and document early fill requests, potential nonadherence, potential drug-seeking behavior, and communication of the following information to the primary prescriber. For other mental health staff this may include documenting any reported AEs of the medication, referring the patient to their prescriber or pharmacist for any medication questions or concerns, and assessment of effectiveness and/or worsening behavior during patient contact.

Limitations

One limitation of this study was the way that data were pulled from patient charts. For example, only 3/200 participants in this study had insomnia per diagnosis codes, whereas that number was substantially higher when chart review was used to assess active prescriptions for sleep aids or documented complaints of insomnia in prescriber progress notes. For this same reason, rates of SUDs must be interpreted with caution as well. SUD diagnosis, both current and in remission were taken into account during data collection. Per diagnosis codes, 36 (18%) veterans in this study had a history of SUD, but this number was higher (31.5%) during chart review. The majority of discrepancies were found when participants reported a history of SUD to the prescriber, but this information was not captured via the problem list or encounter codes. What some may consider a minor omission in documentation can have a large impact on patient care as it is unlikely that prescribers have adequate administrative time to complete a chart review in order to find a complete past medical history as was required of investigators in this study. For this reason, incomplete provider documentation and human error that can occur as a result of a retrospective chart review were also identified as study limitations.

Conclusion

Our data show that there is still substantial room for improvement in the prescribing and monitoring of stimulant medications. The rate of stimulant prescribing inconsistency, prescriber-hopping, and unsupported ADHD diagnosis resulting from formal diagnostic testing warrant a review in the processes for transition of care regarding stimulant medications, both within and outside of this facility. A lack of consistent monitoring was also identified in this study. One of the most appreciable areas of opportunity resulting from this study is the need for consistency in both the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a CPP for stimulant prescribing as well as a chronic stimulant management agreement to provide clear expectations for patients and prescribers prior to and during prescription stimulant use.

Acknowledgments 

We thank Tori Wilhoit, PharmD candidate, and Dana Fischer, PharmD candidate, for their participation in data collection and Courtney Eatmon, PharmD, BCPP, for her general administrative support throughout this study.

Dispensing of prescription stimulant medications, such as methylphenidate or amphetamine salts, has been expanding at a rapid rate over the past 2 decades. An astounding 58 million stimulant medications were prescribed in 2014.^1,2 Adults now exceed youths in the proportion of prescribed stimulant medications.^1,3

Off-label use of prescription stimulant medications, such as for performance enhancement, fatigue management, weight loss, medication-assisted therapy for stimulant use disorders, and adjunctive treatment for certain depressive disorders, is reported to be ≥ 40% of total stimulant use and is much more common in adults.¹ A 2017 study assessing risk of amphetamine use disorder and mortality among veterans prescribed stimulant medications within the Veterans Health Administration (VHA) reported off-label use in nearly 3 of every 5 incident users in 2012.⁴ Off-label use also is significantly more common when prescribed by nonpsychiatric physicians compared with that of psychiatrists.¹

One study assessing stimulant prescribing from 2006 to 2009 found that nearly 60% of adults were prescribed stimulant medications by nonpsychiatrist physicians, and only 34% of those adults prescribed a stimulant by a nonpsychiatrist physician had a diagnosis of attention-deficit hyperactivity disorder (ADHD).⁵ Findings from managed care plans covering years from 2000 to 2004 were similar, concluding that 30% of the adult patients who were prescribed methylphenidate had at least 1 medical claim with a diagnosis of ADHD.⁶ Of the approximately 16 million adults prescribed stimulant medications in 2017, > 5 million of them reported stimulant misuse.³ Much attention has been focused on misuse of stimulant medications by youths and young adults, but new information suggests that increased monitoring is needed among the US adult population. Per the US Department of Veterans Affairs (VA) Academic Detailing Stimulant Dashboard, as of October 2018 the national average of veterans with a documented substance use disorder (SUD) who are also prescribed stimulant medications through the VHA exceeds 20%, < 50% have an annual urine drug screen (UDS), and > 10% are coprescribed opioids and benzodiazepines.The percentage of veterans prescribed stimulant medications in the presence of a SUD has increased over the past decade, with a reported 8.7% incidence in 2002 increasing to 14.3% in 2012.⁴

There are currently no protocols, prescribing restrictions, or required monitoring parameters in place for prescription stimulant use within the Lexington VA Health Care System (LVAHCS). The purpose of this study was to evaluate the prescribing practices at LVAHCS of stimulant medications and identify opportunities for improvement in the prescribing and monitoring of this drug class.

Methods

This study was a single-center quality improvement project evaluating the prescribing practices of stimulant medications within LVAHCS and exempt from institutional review board approval. Veterans were included in the study if they were prescribed amphetamine salts, dextroamphetamine, lisdexamphetamine, or methylphenidate between January 1, 2018 and June 30, 2018; however, the veterans’ entire stimulant use history was assessed. Exclusion criteria included duration of use of < 2 months or < 2 prescriptions filled during the study period. Data for veterans who met the prespecified inclusion and exclusion criteria were collected via chart review and Microsoft SQL Server Management Studio.

Collected data included age, gender, stimulant regimen (drug name, dose, frequency), indication and duration of use, prescriber name and specialty, prescribing origin of initial stimulant medication, and whether stimulant use predated military service. Monitoring of stimulant medications was assessed via UDS at least annually, query of the prescription drug monitoring program (PDMP) at least quarterly, and average time between follow-up appointments with stimulant prescriber.

Monitoring parameters were assessed from January 1, 2017 through June 30, 2018, as it was felt that the 6-month study period would be too narrow to accurately assess monitoring trends. Mental health diagnoses, ADHD diagnostic testing if applicable, documented SUD or stimulant misuse past or present, and concomitant central nervous system (CNS) depressant use also were collected. CNS depressants evaluated were those that have abuse potential or significant psychotropic effects and included benzodiazepines, antipsychotics, opioids, gabapentin/pregabalin, Z-hypnotics, and muscle relaxants.

Results

The majority of participants were male (168/200) with an average age of 43.3 years. Dextroamphetamine/amphetamine was the most used stimulant (48.5%), followed by methylphenidate (40%), and dextroamphetamine (10%). Lisdexamphetamine was the least used stimulant, likely due to its formulary-restricted status within this facility. An extended release (ER) formulation was utilized in 1 of 4 participants, with 1 of 20 participants prescribed a combination of immediate release (IR) and ER formulations. Duration of use ranged from 3 months to 14 years, with an average duration of 4 years (Table 1).

Nearly 40% of participants reported an origin of stimulant initiation outside of LVAHCS. Fourteen percent of participants were started on prescription stimulant medications while active-duty service members. Stimulant medications were initiated at another VA facility in 10.5% of instances, and 15% of participants reported being prescribed stimulant medications by a civilian prescriber prior to receiving them at LVAHCS. Seventy-four of 79 (93.6%) participants with an origin of stimulant prescription outside of LVAHCS reported a US Federal Food and Drug Administration (FDA)-approved indication for use. The majority (87%) of stimulant medications were prescribed by the mental health service, and 25% of initial stimulant prescriptions were written by a single mental health prescriber. Eleven percent of participants were prescribed stimulant medications by multiple specialties, and nearly all participants had > 1 stimulant prescriber over the course of their treatment. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

Stimulant medications were used for FDA-approved indications (ADHD and narcolepsy) in 69.5% of participants. Note, this included patients who maintained an ADHD diagnosis in their medical record even if it was not substantiated with diagnostic testing. Of the participants reporting ADHD as an indication for stimulant use, diagnostic testing was conducted at LVAHCS to confirm an ADHD diagnosis in 58.6% (78/133) participants; 20.5% (16/78) of these diagnostic tests did not support the diagnosis of ADHD. All documented indications for use can be found in Table 2.

Discussion

The source of the initial stimulant prescription was assessed. The majority of veterans had received medical care prior to receiving care at LVAHCS, whether on active duty, from another VA facility throughout the country, or by a private civilian prescriber. The origin of initial stimulant medication and indication for stimulant medication use were patient reported. Requiring medical records from civilian providers prior to continuing stimulant medication is prescriber-dependent and was not available for all participants.

As expected, the majority of participants (87%) received their first stimulant prescription via a prescriber in the mental health specialty, 20 were prescribed stimulant medications from primary care, 4 from the emergency department (ED), and 2 from neurology. Three of the 4 stimulant prescriptions written in the ED were for continuity of care until the veteran could have an appointment with a mental health or primary care provider, and the other was prescribed by a mental health nurse practitioner for a veteran who presented to the ED with complaints of ADHD-like symptoms. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

The reasons for discontinuation included a positive UDS result for cocaine, psychosis, broken narcotic contract, ADHD diagnosis not supported by psychological testing, chronic bipolar disorder secondary to stimulant use, diversion, stimulant misuse, and lack of indication for use. There also were a handful of veterans whose VA prescribers declined to initiate prescription stimulant medications for various reasons, so the veteran sought care from a civilian prescriber who prescribed stimulant medications, then returned to the VA for medication management, and stimulant medications were continued. Fourteen percent (28/200) of participants had multiple indications for use at some point during stimulant medication therapy. Eight of those were a reasonable change from ADHD to ADHD-like symptoms when diagnosis was not substantiated by testing. The cause of other changes in indication for use was not well documented and often unclear. One veteran had 4 different indications for use documented in the medical record, often changing with each change in prescriber. It appeared that the most recent prescriber was uncertain of the actual indication for use but did not want to discontinue the medication. This prescriber documented that the stimulant medication should continue for presumed ADHD/mood/fatigue/cognitive dysfunction, which were all of the indications documented by the veteran’s previous prescribers.

Reasons for Discontinuation

ADHD was the most prominent indication for use, although the indication was changed to ADHD-like symptoms in several veterans for whom diagnostic testing did not support the ADHD diagnosis. Seventy-eight of 133 veterans prescribed stimulant medications for ADHD received diagnostic testing via a psychologist at LVAHCS. For the 11 veterans who had testing after stimulant initiation, a stimulant-free period was required prior to testing to ensure an accurate diagnosis. For 21% of veterans, the ADHD diagnosis was unsubstantiated by formal testing; however, all of these veterans continued stimulant medication use. For 1 veteran, the psychologist performing the testing documented new diagnoses, including moderate to severe stimulant use disorder and malingering both for PTSD and ADHD. The rate of stimulant prescribing inconsistency, “prescriber-hopping,” and unsupported ADHD diagnosis results warrant a conversation about expectations for transitions of care regarding stimulant medications, not only from outside to inside LVAHCS, but from prescriber to prescriber within the facility.

In some cases, stimulant medications were discontinued by a prescriber secondary to a worsening of another mental health condition. More than half of the participants in this study had an anxiety disorder diagnosis. Whether or not anxiety predated stimulant use or whether the use of stimulant medications contributed to the diagnosis and thus the addition of an additional CNS depressant to treat anxiety may be an area of research for future consideration. Although bipolar disorder, anxiety disorders, psychosis, and SUD are not contraindications for use of stimulant medications, caution must be used in patients with these diagnoses. Prescribers must weigh risks vs benefits as well as perform close monitoring during use. Similarly, one might look further into stimulant medications prescribed for fatigue and assess the role of any simultaneously prescribed CNS depressants. Is the stimulant being used to treat the adverse effect (AE) of another medication? In 2 documented instances in this study, a psychologist conducted diagnostic testing who reported that the veteran did not meet the criteria for ADHD but that a stimulant may help counteract the iatrogenic effect of anticonvulsants. In both instances stimulant use continued.

Prescription Monitoring

Polysubstance use disorder (5%) was the third most common SUD recorded among study participants. The majority of those with polysubstance use disorder reported abuse/misuse of illicit or prescribed stimulants. Stimulant abuse/misuse was documented in 25 of 200 (12.5%) study participants. In several instances, abuse/misuse was detected by the LVAHCS delivery coordination pharmacist who tracks patterns of early fill requests and prescriptions reported lost/stolen. This pharmacist may request that the prescriber obtain PDMP query, UDS, or pill count if concerning patterns are noted. Lisdexamphetamine is a formulary-restricted medication at LVAHCS, but it was noted to be approved for use when prescribers requested an abuse-deterrent formulation. Investigators noticed a trend in veterans whose prescriptions exceeded the recommended maximum dosage also having stimulant abuse/misuse documented in their medical record. The highest documented total daily dose in this study was 120-mg amphetamine salts IR for ADHD, compared with the normal recommended dosing range of 5 to 40 mg/d for the same indication.

Various modalities were used to monitor participants but less than half of veterans had an annual UDS, quarterly PDMP query, and quarterly prescriber follow-up. PDMP queries and prescriber follow-up was assessed quarterly as would be reasonable given that private sector practitioners may issue multiple prescriptions authorizing the patient to receive up to a 90-day supply.⁷ Prescriber follow-up ranged from 1 to 15 months. A longer time to follow-up was seen more frequently in stimulant medications prescribed by primary care as compared with that of mental health.

Clinical Practice Protocol

Data from this study were collected with the intent to identify opportunities for improvement in the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a facility-specific clinical practice protocol (CPP) for stimulant prescribing. It may also be beneficial to formulate a chronic stimulant management agreement between patient and prescriber to provide informed consent and clear expectations prior to stimulant medication initiation.

A CPP could be used to establish stimulant prescribing rules within a facility, which may limit who can prescribe stimulant medications or include a review process and/or required documentation in the medical record when being prescribed outside of specified dosing range and indications for use designated in the CPP or other evidence-based guidelines. Transition of care was found to be an area of opportunity in this study, which could be mitigated with the requirement of a baseline assessment prior to stimulant initiation with the expectation that it be completed regardless of prior prescription stimulant medication use. There was a lack of consistent monitoring for participants in this study, which may be improved if required monitoring parameters and frequency were provided for prescribers. For example, monitoring of heart rate and blood pressure was not assessed in this study, but a CPP may include monitoring vital signs before and after each dose change and every 6 months, per recommendation from the National Institute for Health and Care Excellence ADHD Diagnosis and Management guideline published in 2018.⁸The CPP may list the responsibilities of all those involved in the prescribing of stimulant medications, such as mental health service leadership, prescribers, nursing staff, pharmacists, social workers, psychologists, and other mental health staff. For prescribers this may include a thorough baseline assessment and criteria for use that must be met prior to stimulant initiation, documentation that must be included in the medical record and required monitoring during stimulant treatment, and expectations for increased monitoring and/or termination of treatment with nonadherence, diversion, or abuse/misuse.

The responsibilities of pharmacists may include establishing criteria for use of nonformulary and restricted agents as well as completion of nonformulary/restricted requests, reviewing dosages that exceed the recommended FDA daily maximum, reviewing uncommon off-label uses of stimulant medications, review and document early fill requests, potential nonadherence, potential drug-seeking behavior, and communication of the following information to the primary prescriber. For other mental health staff this may include documenting any reported AEs of the medication, referring the patient to their prescriber or pharmacist for any medication questions or concerns, and assessment of effectiveness and/or worsening behavior during patient contact.

Limitations

One limitation of this study was the way that data were pulled from patient charts. For example, only 3/200 participants in this study had insomnia per diagnosis codes, whereas that number was substantially higher when chart review was used to assess active prescriptions for sleep aids or documented complaints of insomnia in prescriber progress notes. For this same reason, rates of SUDs must be interpreted with caution as well. SUD diagnosis, both current and in remission were taken into account during data collection. Per diagnosis codes, 36 (18%) veterans in this study had a history of SUD, but this number was higher (31.5%) during chart review. The majority of discrepancies were found when participants reported a history of SUD to the prescriber, but this information was not captured via the problem list or encounter codes. What some may consider a minor omission in documentation can have a large impact on patient care as it is unlikely that prescribers have adequate administrative time to complete a chart review in order to find a complete past medical history as was required of investigators in this study. For this reason, incomplete provider documentation and human error that can occur as a result of a retrospective chart review were also identified as study limitations.

Conclusion

Our data show that there is still substantial room for improvement in the prescribing and monitoring of stimulant medications. The rate of stimulant prescribing inconsistency, prescriber-hopping, and unsupported ADHD diagnosis resulting from formal diagnostic testing warrant a review in the processes for transition of care regarding stimulant medications, both within and outside of this facility. A lack of consistent monitoring was also identified in this study. One of the most appreciable areas of opportunity resulting from this study is the need for consistency in both the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a CPP for stimulant prescribing as well as a chronic stimulant management agreement to provide clear expectations for patients and prescribers prior to and during prescription stimulant use.

Acknowledgments 

We thank Tori Wilhoit, PharmD candidate, and Dana Fischer, PharmD candidate, for their participation in data collection and Courtney Eatmon, PharmD, BCPP, for her general administrative support throughout this study.

Dispensing of prescription stimulant medications, such as methylphenidate or amphetamine salts, has been expanding at a rapid rate over the past 2 decades. An astounding 58 million stimulant medications were prescribed in 2014.^1,2 Adults now exceed youths in the proportion of prescribed stimulant medications.^1,3

Off-label use of prescription stimulant medications, such as for performance enhancement, fatigue management, weight loss, medication-assisted therapy for stimulant use disorders, and adjunctive treatment for certain depressive disorders, is reported to be ≥ 40% of total stimulant use and is much more common in adults.¹ A 2017 study assessing risk of amphetamine use disorder and mortality among veterans prescribed stimulant medications within the Veterans Health Administration (VHA) reported off-label use in nearly 3 of every 5 incident users in 2012.⁴ Off-label use also is significantly more common when prescribed by nonpsychiatric physicians compared with that of psychiatrists.¹

One study assessing stimulant prescribing from 2006 to 2009 found that nearly 60% of adults were prescribed stimulant medications by nonpsychiatrist physicians, and only 34% of those adults prescribed a stimulant by a nonpsychiatrist physician had a diagnosis of attention-deficit hyperactivity disorder (ADHD).⁵ Findings from managed care plans covering years from 2000 to 2004 were similar, concluding that 30% of the adult patients who were prescribed methylphenidate had at least 1 medical claim with a diagnosis of ADHD.⁶ Of the approximately 16 million adults prescribed stimulant medications in 2017, > 5 million of them reported stimulant misuse.³ Much attention has been focused on misuse of stimulant medications by youths and young adults, but new information suggests that increased monitoring is needed among the US adult population. Per the US Department of Veterans Affairs (VA) Academic Detailing Stimulant Dashboard, as of October 2018 the national average of veterans with a documented substance use disorder (SUD) who are also prescribed stimulant medications through the VHA exceeds 20%, < 50% have an annual urine drug screen (UDS), and > 10% are coprescribed opioids and benzodiazepines.The percentage of veterans prescribed stimulant medications in the presence of a SUD has increased over the past decade, with a reported 8.7% incidence in 2002 increasing to 14.3% in 2012.⁴

There are currently no protocols, prescribing restrictions, or required monitoring parameters in place for prescription stimulant use within the Lexington VA Health Care System (LVAHCS). The purpose of this study was to evaluate the prescribing practices at LVAHCS of stimulant medications and identify opportunities for improvement in the prescribing and monitoring of this drug class.

Methods

This study was a single-center quality improvement project evaluating the prescribing practices of stimulant medications within LVAHCS and exempt from institutional review board approval. Veterans were included in the study if they were prescribed amphetamine salts, dextroamphetamine, lisdexamphetamine, or methylphenidate between January 1, 2018 and June 30, 2018; however, the veterans’ entire stimulant use history was assessed. Exclusion criteria included duration of use of < 2 months or < 2 prescriptions filled during the study period. Data for veterans who met the prespecified inclusion and exclusion criteria were collected via chart review and Microsoft SQL Server Management Studio.

Collected data included age, gender, stimulant regimen (drug name, dose, frequency), indication and duration of use, prescriber name and specialty, prescribing origin of initial stimulant medication, and whether stimulant use predated military service. Monitoring of stimulant medications was assessed via UDS at least annually, query of the prescription drug monitoring program (PDMP) at least quarterly, and average time between follow-up appointments with stimulant prescriber.

Monitoring parameters were assessed from January 1, 2017 through June 30, 2018, as it was felt that the 6-month study period would be too narrow to accurately assess monitoring trends. Mental health diagnoses, ADHD diagnostic testing if applicable, documented SUD or stimulant misuse past or present, and concomitant central nervous system (CNS) depressant use also were collected. CNS depressants evaluated were those that have abuse potential or significant psychotropic effects and included benzodiazepines, antipsychotics, opioids, gabapentin/pregabalin, Z-hypnotics, and muscle relaxants.

Results

The majority of participants were male (168/200) with an average age of 43.3 years. Dextroamphetamine/amphetamine was the most used stimulant (48.5%), followed by methylphenidate (40%), and dextroamphetamine (10%). Lisdexamphetamine was the least used stimulant, likely due to its formulary-restricted status within this facility. An extended release (ER) formulation was utilized in 1 of 4 participants, with 1 of 20 participants prescribed a combination of immediate release (IR) and ER formulations. Duration of use ranged from 3 months to 14 years, with an average duration of 4 years (Table 1).

Nearly 40% of participants reported an origin of stimulant initiation outside of LVAHCS. Fourteen percent of participants were started on prescription stimulant medications while active-duty service members. Stimulant medications were initiated at another VA facility in 10.5% of instances, and 15% of participants reported being prescribed stimulant medications by a civilian prescriber prior to receiving them at LVAHCS. Seventy-four of 79 (93.6%) participants with an origin of stimulant prescription outside of LVAHCS reported a US Federal Food and Drug Administration (FDA)-approved indication for use. The majority (87%) of stimulant medications were prescribed by the mental health service, and 25% of initial stimulant prescriptions were written by a single mental health prescriber. Eleven percent of participants were prescribed stimulant medications by multiple specialties, and nearly all participants had > 1 stimulant prescriber over the course of their treatment. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

Stimulant medications were used for FDA-approved indications (ADHD and narcolepsy) in 69.5% of participants. Note, this included patients who maintained an ADHD diagnosis in their medical record even if it was not substantiated with diagnostic testing. Of the participants reporting ADHD as an indication for stimulant use, diagnostic testing was conducted at LVAHCS to confirm an ADHD diagnosis in 58.6% (78/133) participants; 20.5% (16/78) of these diagnostic tests did not support the diagnosis of ADHD. All documented indications for use can be found in Table 2.

Discussion

The source of the initial stimulant prescription was assessed. The majority of veterans had received medical care prior to receiving care at LVAHCS, whether on active duty, from another VA facility throughout the country, or by a private civilian prescriber. The origin of initial stimulant medication and indication for stimulant medication use were patient reported. Requiring medical records from civilian providers prior to continuing stimulant medication is prescriber-dependent and was not available for all participants.

As expected, the majority of participants (87%) received their first stimulant prescription via a prescriber in the mental health specialty, 20 were prescribed stimulant medications from primary care, 4 from the emergency department (ED), and 2 from neurology. Three of the 4 stimulant prescriptions written in the ED were for continuity of care until the veteran could have an appointment with a mental health or primary care provider, and the other was prescribed by a mental health nurse practitioner for a veteran who presented to the ED with complaints of ADHD-like symptoms. More than 10% of veterans had their stimulant medication discontinued by one prescriber and then restarted by another prescriber.

The reasons for discontinuation included a positive UDS result for cocaine, psychosis, broken narcotic contract, ADHD diagnosis not supported by psychological testing, chronic bipolar disorder secondary to stimulant use, diversion, stimulant misuse, and lack of indication for use. There also were a handful of veterans whose VA prescribers declined to initiate prescription stimulant medications for various reasons, so the veteran sought care from a civilian prescriber who prescribed stimulant medications, then returned to the VA for medication management, and stimulant medications were continued. Fourteen percent (28/200) of participants had multiple indications for use at some point during stimulant medication therapy. Eight of those were a reasonable change from ADHD to ADHD-like symptoms when diagnosis was not substantiated by testing. The cause of other changes in indication for use was not well documented and often unclear. One veteran had 4 different indications for use documented in the medical record, often changing with each change in prescriber. It appeared that the most recent prescriber was uncertain of the actual indication for use but did not want to discontinue the medication. This prescriber documented that the stimulant medication should continue for presumed ADHD/mood/fatigue/cognitive dysfunction, which were all of the indications documented by the veteran’s previous prescribers.

Reasons for Discontinuation

ADHD was the most prominent indication for use, although the indication was changed to ADHD-like symptoms in several veterans for whom diagnostic testing did not support the ADHD diagnosis. Seventy-eight of 133 veterans prescribed stimulant medications for ADHD received diagnostic testing via a psychologist at LVAHCS. For the 11 veterans who had testing after stimulant initiation, a stimulant-free period was required prior to testing to ensure an accurate diagnosis. For 21% of veterans, the ADHD diagnosis was unsubstantiated by formal testing; however, all of these veterans continued stimulant medication use. For 1 veteran, the psychologist performing the testing documented new diagnoses, including moderate to severe stimulant use disorder and malingering both for PTSD and ADHD. The rate of stimulant prescribing inconsistency, “prescriber-hopping,” and unsupported ADHD diagnosis results warrant a conversation about expectations for transitions of care regarding stimulant medications, not only from outside to inside LVAHCS, but from prescriber to prescriber within the facility.

In some cases, stimulant medications were discontinued by a prescriber secondary to a worsening of another mental health condition. More than half of the participants in this study had an anxiety disorder diagnosis. Whether or not anxiety predated stimulant use or whether the use of stimulant medications contributed to the diagnosis and thus the addition of an additional CNS depressant to treat anxiety may be an area of research for future consideration. Although bipolar disorder, anxiety disorders, psychosis, and SUD are not contraindications for use of stimulant medications, caution must be used in patients with these diagnoses. Prescribers must weigh risks vs benefits as well as perform close monitoring during use. Similarly, one might look further into stimulant medications prescribed for fatigue and assess the role of any simultaneously prescribed CNS depressants. Is the stimulant being used to treat the adverse effect (AE) of another medication? In 2 documented instances in this study, a psychologist conducted diagnostic testing who reported that the veteran did not meet the criteria for ADHD but that a stimulant may help counteract the iatrogenic effect of anticonvulsants. In both instances stimulant use continued.

Prescription Monitoring

Polysubstance use disorder (5%) was the third most common SUD recorded among study participants. The majority of those with polysubstance use disorder reported abuse/misuse of illicit or prescribed stimulants. Stimulant abuse/misuse was documented in 25 of 200 (12.5%) study participants. In several instances, abuse/misuse was detected by the LVAHCS delivery coordination pharmacist who tracks patterns of early fill requests and prescriptions reported lost/stolen. This pharmacist may request that the prescriber obtain PDMP query, UDS, or pill count if concerning patterns are noted. Lisdexamphetamine is a formulary-restricted medication at LVAHCS, but it was noted to be approved for use when prescribers requested an abuse-deterrent formulation. Investigators noticed a trend in veterans whose prescriptions exceeded the recommended maximum dosage also having stimulant abuse/misuse documented in their medical record. The highest documented total daily dose in this study was 120-mg amphetamine salts IR for ADHD, compared with the normal recommended dosing range of 5 to 40 mg/d for the same indication.

Various modalities were used to monitor participants but less than half of veterans had an annual UDS, quarterly PDMP query, and quarterly prescriber follow-up. PDMP queries and prescriber follow-up was assessed quarterly as would be reasonable given that private sector practitioners may issue multiple prescriptions authorizing the patient to receive up to a 90-day supply.⁷ Prescriber follow-up ranged from 1 to 15 months. A longer time to follow-up was seen more frequently in stimulant medications prescribed by primary care as compared with that of mental health.

Clinical Practice Protocol

Data from this study were collected with the intent to identify opportunities for improvement in the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a facility-specific clinical practice protocol (CPP) for stimulant prescribing. It may also be beneficial to formulate a chronic stimulant management agreement between patient and prescriber to provide informed consent and clear expectations prior to stimulant medication initiation.

A CPP could be used to establish stimulant prescribing rules within a facility, which may limit who can prescribe stimulant medications or include a review process and/or required documentation in the medical record when being prescribed outside of specified dosing range and indications for use designated in the CPP or other evidence-based guidelines. Transition of care was found to be an area of opportunity in this study, which could be mitigated with the requirement of a baseline assessment prior to stimulant initiation with the expectation that it be completed regardless of prior prescription stimulant medication use. There was a lack of consistent monitoring for participants in this study, which may be improved if required monitoring parameters and frequency were provided for prescribers. For example, monitoring of heart rate and blood pressure was not assessed in this study, but a CPP may include monitoring vital signs before and after each dose change and every 6 months, per recommendation from the National Institute for Health and Care Excellence ADHD Diagnosis and Management guideline published in 2018.⁸The CPP may list the responsibilities of all those involved in the prescribing of stimulant medications, such as mental health service leadership, prescribers, nursing staff, pharmacists, social workers, psychologists, and other mental health staff. For prescribers this may include a thorough baseline assessment and criteria for use that must be met prior to stimulant initiation, documentation that must be included in the medical record and required monitoring during stimulant treatment, and expectations for increased monitoring and/or termination of treatment with nonadherence, diversion, or abuse/misuse.

The responsibilities of pharmacists may include establishing criteria for use of nonformulary and restricted agents as well as completion of nonformulary/restricted requests, reviewing dosages that exceed the recommended FDA daily maximum, reviewing uncommon off-label uses of stimulant medications, review and document early fill requests, potential nonadherence, potential drug-seeking behavior, and communication of the following information to the primary prescriber. For other mental health staff this may include documenting any reported AEs of the medication, referring the patient to their prescriber or pharmacist for any medication questions or concerns, and assessment of effectiveness and/or worsening behavior during patient contact.

Limitations

One limitation of this study was the way that data were pulled from patient charts. For example, only 3/200 participants in this study had insomnia per diagnosis codes, whereas that number was substantially higher when chart review was used to assess active prescriptions for sleep aids or documented complaints of insomnia in prescriber progress notes. For this same reason, rates of SUDs must be interpreted with caution as well. SUD diagnosis, both current and in remission were taken into account during data collection. Per diagnosis codes, 36 (18%) veterans in this study had a history of SUD, but this number was higher (31.5%) during chart review. The majority of discrepancies were found when participants reported a history of SUD to the prescriber, but this information was not captured via the problem list or encounter codes. What some may consider a minor omission in documentation can have a large impact on patient care as it is unlikely that prescribers have adequate administrative time to complete a chart review in order to find a complete past medical history as was required of investigators in this study. For this reason, incomplete provider documentation and human error that can occur as a result of a retrospective chart review were also identified as study limitations.

Conclusion

Our data show that there is still substantial room for improvement in the prescribing and monitoring of stimulant medications. The rate of stimulant prescribing inconsistency, prescriber-hopping, and unsupported ADHD diagnosis resulting from formal diagnostic testing warrant a review in the processes for transition of care regarding stimulant medications, both within and outside of this facility. A lack of consistent monitoring was also identified in this study. One of the most appreciable areas of opportunity resulting from this study is the need for consistency in both the prescribing and monitoring of stimulant medications. From the above results investigators concluded that this facility may benefit from implementation of a CPP for stimulant prescribing as well as a chronic stimulant management agreement to provide clear expectations for patients and prescribers prior to and during prescription stimulant use.

Acknowledgments 

We thank Tori Wilhoit, PharmD candidate, and Dana Fischer, PharmD candidate, for their participation in data collection and Courtney Eatmon, PharmD, BCPP, for her general administrative support throughout this study.

The Veterans Health Administration (VHA) provides care for 9 million veterans at 1,255 health care sites linked to one of 170 local medical systems.¹ Recognizing that providing timely care requires effective access management, the US Congress mandated training of VHA staff to manage and improve access to care but did not provide additional local funds for new positions.² In response, the VHA created the group practice manager (GPM), a new position responsible for improving clinical practice management and unifying access improvement across leadership levels, professions, and services within each local medical system.

In May 2015, the VHA began hiring and training GPMs to spearhead management of access to services. The US Department of Veterans Affairs (VA) Office of Veteran Access to Care spearheaded GPM training, including face-to-face sessions, national calls, webinars, and educational materials. Five local medical systems were selected by the VA Office of Veteran Access to Care to implement the GPM role to allow for an early evaluation of the program that would inform a subsequent nationwide rollout. Implementation of the GPM role remained in the hands of local medical systems.

Longer wait times are shown to impact patient health.^3,4 Open access scheduling and other patient-centered access management interventions have been shown to improve availability of primary care appointments.⁵ However, little empirical evidence exists regarding the managers who focus on clinic access interventions. While the nonpeer-reviewed literature includes references to such roles, including GPMs, the empirical literature has focused on external practice faciliators,^6-8 “mid-level managers,”⁹ and clinic staff.¹⁰ We found no peer-reviewed articles on the needs and experiences of practice managers who are focused on improving access. The purpose of this study was to examine GPM prototype sites to both enhance subsequent nationwide implementation and to advance empirical literature on managing patient access within health care.

Methods

In 2015, the VA identified 5 prototype sites representing diverse geographic locations, size, and complexity for the implementation of the GPM role (Table 1). These sites self-identified as having clinical practice management experience. GPMs attended 4 training sessions between February and August 2015.

Data Collection

Participants from each prototype site included GPMs, national trainers, clinic leaders, and frontline staff. Table 2 includes the roles and sample size. Participants were recruited through purposive sampling followed by snowball sampling until thematic saturation was reached (the point at which subsequent data fail to produce new findings across sites and roles of interest).

Guided by the Consolidated Framework for Implementation Research (CFIR), the research team developed semistructured interview guides tailored to participants’ roles to elicit rich descriptions regarding overall impressions, practice management strategies, goals, activities, relationship to clinic roles, data analytics usage, challenges, barriers, and facilitators.¹¹ These guides included open-ended questions and structured prompts utilizing participant language for follow-up probes to minimize interviewing bias (eAppendix:

Data Analysis

Data were analyzed using iterative deductive and inductive content analysis.¹² Deductive content analysis consisted of identifying quotes that fit within preidentified categories (ie, perceptions of national effort, organizational structure for GPM, challenges, facilitators, metrics and tools, and mobilizing access culture) developed by the interdisciplinary research team. Further content analysis entailed open-coding and iteratively revisiting and reconciling codes associated within each preidentified category as new codes emerged. The team analyzed the resulting codes to inductively and iteratively identify and stabilize themes regarding the GPM role: roles and tasks, GPM characteristics, issues, and challenges. Through this process we moved coded data to reconciled descriptions suited to addressing the purposes of this study. Dedoose 7.0.23 software was used for qualitative data management and analysis.

Results

The study identified participants’ overall impressions of the GPM initiative and key themes within 4 major domains regarding implementing the GPM role: roles and tasks (implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff); GPM characteristics (familiarity with clinical services, knowledge of VHA systems, ability to analyze patient data, communication skills, and the ability to work with others); and issues, and challenges (technical, social, and structural).

Overall Impressions

Interviewees perceived the GPM initiative as a consolidation of existing distributed responsibilities into one role that directly reported to local top-level management with indirect reporting to national leaders. Many of the sites reported that they had designated or planned to designate a role resembling the GPM prior to the initiative. “There are staff who’ve been doing some of this work all along,” a GPM noted. “We just didn’t have them grouped together. They weren’t necessarily all working in the same type of service under the same type of structure.”

Whether the GPM position was new or not, participants referenced the importance and challenges of engaging the local facility in recognizing the agency associated with the GPM position. According to national support, the staff are trying to get the facility to understand “why the group practice manager is so important… we’ve got to embed that standard position in the system.”

While the GPM was recognized as the hub of access management, respondents recognized that transformation regarding access involved many players. “We have to create [an] orchestrated team inside each facility,” an advisor argued.

Respondents discussed how the initiative allows local facilities to appoint a specific person with a specific title and role who helps facilitate, organize, and legitimize an access focus at their sites. One GPM interviewee noted how the initiative helped refocus some of their previously less centralized efforts. “We’ve always looked at productivity; we’ve always looked at access; we’ve always looked at efficiency. I think the bigger difference is now there are individuals identified in the clinics, as practice managers as well…I interact with them. They interact with individual clinic staff, and it’s more of a group process than a single individual.”

The value of having tools available and being able to track and manage patient care as a specific example of the positive impact of this new role was noted by participants. A GPM noted that many health care providers will be happy to have tools to better manage their services and a process “that flows from a service level all the way up to executive management, where there is a common interest in making those things happen—I think that’s going to be a tremendous help.”

Participants expressed concern that the national GPM rollout would be a one-size-fits-all approach. These respondents emphasized the need to have the flexibility to customize their activities to meet their unique site and patient needs.

GPM Roles and Tasks

Participants described 4 primary roles that the GPM was expected to fill: implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff. Some activities overlapped in that they served to support multiple role areas (Figure 1).

Implementing clinic practice management. In the early stages of the initiative, the GPM’s primary role was to prepare the facility to implement a standardized set of clinic practice management (CPM) team processes. Part of standardizing the CPM process was defining the scope and tasks of the GPM, which requires significant planning for the implementation. “My big job is to finalize what we think group practice management is going to look [like] here,” a GPM reported.

Each prototype site had latitude to interpret the GPM initiative in a way that would work in their context within given VHA boundaries and ongoing initiatives. To achieve the high-level vision and purpose, the GPM first had to develop action plans that accounted for the operating environment of the facility. According to one GPM, VA national officials are “constantly” asking for action plans, which required significant time by specific deadlines. “They want an action plan [and to] clean up all your consults, [and to] clean up all your recall reminders.”

Leading on improving access efforts. Participants saw the GPM as the central staff member responsible for providing oversight of any activities and people involved in improving access. “I ensure everybody is doing what they’re supposed to do,” one GPM reported. When the GPM sees areas that are not being addressed, the individual tries to develop a process or training to “close those gaps.”

GPMs promoted an awareness of their goals, changes in process, and new tools accompanying the initiative. However, other access initiatives were occurring simultaneously creating confusion for health care providers and patients; thus GPMs found they were managing a wide array of related initiatives.

GPMs have to negotiate with leaders across the VHA facility, many of whom operated at a higher leadership level and had different priorities, to address access problems.

“I’m a lieutenant as a GPM in a clinic, a GPM noted. “How is the lieutenant going to talk to a major or a colonel in the clinic and say your clinic has problems. How[‘s] that lieutenant...going to do that? With people skills!”

Managing expectations about the speed and to what extent a problem could be resolved was an important part of the GPM leadership role. “I see myself as managing expectations both up to the leadership and down to the frontline,” a GPM explained. “I find myself talking to leadership [about] our progress. But at the same time, we have to say, ‘not everything can be fixed overnight.’”

Providing leadership on access-related issues included developing a range of options for addressing patient access problems. One analytics manager recounted how the GPM role led to evaluating how physical space limited efficiency in clinic flow. The first step was identifying possible additional rooms to improve clinic flow. This required working with the space committee to “get someone to look at our overarching space and find someplace else for them to sit” to avoid adding to congestion in the clinic area.
 

Supporting data analytics. Given the importance of data analytics, GPMs had a critical role in helping to ensure that the data were accurate and clean. At one facility the GPM and the business managers, “are doing a tremendous amount to clean up our data to make it accurately reflect what it is that we’re doing,” reported a community clinic director.

GPMs routinely immersed themselves in the data to understand access issues. GPMs worked with clinic leaders to identify the underlying causes and various solutions. The GPMs maintained access through administrative scrubbing of the data and finding “smart ways to get patients scheduled,” a GPM explained. “I don’t think our facility would have taken care of as many veterans in the time frame as we did....We’ve cleared over 4,000 consults that were older than 90 days. We have cleared thousands and thousands of weekly reminders.”

GPMs expressed the need for aggregated (ie, dashboard) and standardized information to efficiently address access issues. “I would like to have some more standardization on what’s being reviewed; it seems to change frequently, and so [to] be able to track and trend and have something given to me to review,” one health care provider requested. On the other hand, participants also described a need for decision support tools that would lead to action aligned with best practices. “Instead of a dashboard or something that’s just measuring their performance, it’s more something that they can look at and take action” a national support staff advisor suggested.

Enabling self and staff. GPMs felt they were most effective if they enabled themselves and stakeholders through training and by cultivating relationships and team building. Figure 2 illustrates the various stakeholders GPMs reported engaging with. The GPMS should be building relationships, bridging relationships, developing trust, and then providing a higher level of hands-on management. However, “that doesn’t really happen right now, day to day,” one member of leadership reported.

Key topics in GPM leadership training included both soft skills (change management, culture change, and negotiation skills) and crucial analytic/technical training (understanding each metric and dashboard available, data analytics, and supply/demand balancing techniques). The GPMs not only wanted to understand metrics as part of their training, but also want to know what to do about them.

An “operationalization” training approach (discerning the meaning of data, data-based decision making, and determining action from multiple options) inspired by real-life situations was preferred by participants. Other effective learning structures included job aids in the form of templated Gantt charts, process maps to guide GPMs through implementation of new processes, formalized peer learning (accumulated field insights shared during training courses), and informal peer sharing of direct experiences during calls.

GPMs also emphasized training for frontline clinical and support staff, including schedulers. VHA schedulers typically have less education and experience higher turnover rates than do other clinic staff, yet they carry out complex and critical tasks. Providing training and ensuring that any materials developed for training and education were appropriate to the level of education of schedulers was an important task for GPMs. “If they don’t understand all of the scheduling principles and potential,” one GPM explained, “we will not be maximizing the utilization of our parts.”

GPMs also provided informal education to clinicians. Participants noted GPMs have to avoid appearing to overstep their positions or presuming more knowledge and expertise than clinicians. They “have to be able to teach a physician without being overbearing, in a way a physician will accept it as advisement,” one program leader reported.
 

GPM knowledge, skills, and abilities. GPMs presented a complex range of knowledge, skills, and abilities, including clinical, administrative, analytics, and people skills. All interviewees reported that their prior education and experience did not sufficiently train them for the GPM role. GPMs identified a willingness to learn quickly as a critical characteristic. Many GPMs tended to have a formal education in health administration or business (eg, MBAs); others had administrative experience (eg, administrative assistance to executive leadership) or clinical training (eg, physician assistant). Detailed clinical knowledge was not expected, but clinical familiarity was helpful.

Some interviewees also mentioned previous experience and familiarity with the VHA system specifically as an advantage. This was especially true for VA outpatient flows, clinic flows, and understanding what an outpatient is in a VA context. Interviewees noted the importance of GPMs needing to be able to analyze patient demand metrics and underlying data in order to determine supply of providers and then to allocate adequate resources to complement providers. Forecasting skills were referenced as a key point. “They need to be able to be assured that they can recruit more providers if needed,” a national support staff advisor noted.

Given the importance of developing effective relationships, communication skills were mentioned by most participants and underscored as critical to establishing trust between GPMs and others as the initiative was being implemented. Interviewees indicated that relationship building was further enhanced when GPMs possessed the ability to “work with” rather than command clinicians and staff; navigate politics; and were respectful of other people’s knowledge, skills, abilities, and status. “They have to work with the nursing staff and teach them,” a leader described, “so that people understand that we are going to a different place to achieve our primary objectives and goals.”

Issues and Challenges

Participants identified several technical, social, and structural challenges and barriers to successfully implementing the GPM role.

Technical challenges. Recurring themes across all phases of data analytics were GPMs’ capability to challenge data use and use large volumes of information from multiple data sources (entering and accessing data; “drilling down” from summaries; generating reports; and analyzing and interpreting resulting metrics). Interviewees reported that information assessment and analytic support were not consistent. One GPM had a data analyst pulling reports needed to support clinical units while other GPMs trained staff to pull data. Even with support, some GPMs had issues due to limited information technology (IT) skills or access privileges leading to inefficiencies and delays. “Whenever I need anything from a programmer, I have to go through, you know, the IT gods in the sky,” one GPM remarked. “That usually takes a few months or more.”

Social challenges. Instituting the GPM role was a cultural change, and interviewees reported needing to address resistance to CPM model efforts. Resistance to change “is particularly hard in the VA just because it has a unique culture,” one leader noted. “There is a comfort in the legacy way of doing things.” The GPM initiative was introduced during a time when other national level initiatives were being implemented throughout the VHA. Fulfilling requests for information for these initiatives became the responsibility of the GPM and their team, which diverted attention from the mandate to improve access. Furthermore, GPMs were often considered the “change communicators” to clinics putting them in the role of “bad messenger,” which degraded trust and made it difficult to partner with clinicians.

Efforts to work through change management and build relationships included general program awareness presentation to internal stakeholders; including key stakeholders in GPM committees; pre-emptive conversations with unit chiefs; creating awareness of the GPM activities and progress through formal and informal update meetings; and identifying successes regarding access.

Structural challenges. The GPM role did not have direct supervision over clinical and administrative leaders, making it challenging to enact change. GPMs reported that “they do not always have authority over the area that they are being asked to manage,” which made their work difficult, requiring strong negotiation skills and political savvy to affect change. However, as the clinic staff and providers saw how the GPM could support and positively impact their practice, these challenges began to subside.

Discussion

This study provides empirical evidence regarding the implementation of a new access management strategy for health care systems focused on improving timeliness of care. First, the GPM position was seen as critical at each facility, as a single point person, to help local system leaders respond effectively to both national mandates and local context. Second, requiring the GPMs to report to the medical center director or chief of staff was important for integrating access perspectives across service lines and to facilitate a strong GPM role in strategic planning. Third, the intentional flexibility of the access management initiative, beyond the nationally specified aspects of the GPM role, was key for allowing individual sites to adapt to unique local challenges, resources, and population demands. Fourth, the initiative provided GPMs with opportunities to learn important skills and support the acquisition, utilization, and communication of a tremendous range of data toward responsive action.

According to our respondents, the GPM role demands functioning across a broad set of responsibilities; understanding the big picture as well as the complex underlying variables; engaging facility leaders, clinical and administrative staff; and prioritizing competing national and local demands. Consistent with previous findings, effective GPMs must possess a complex set of skills (interpersonal, analytic, and leadership) and the ability to create a supporting team.¹³

In practice, improving access at individual sites of care (VA medical centers and community-based outpatient clinics) poses significant challenges, especially in the early stages, even with the assistance of a GPM. For example, some respondents reported being overwhelmed by the volume of available data and dashboards, and responding to current requests for data analysis and dissemination sometimes impeded long range planning. Multiple national access-related initiatives and local pressures also generated excessive and potentially conflicting demands. Thus, while the creation of a GPM position seemed to be essential for the pilot sites to improve local access and timeliness to care, success also requires ongoing national and facility-wide communication, education, and support. Ongoing data analysis training and support will be critical to ensuring the sustainability of the position. Last, recruiting GPMs with the needed complex skill set may prove to be challenging, and it will be important to provide resources to identify, attract, and retain well-qualified GPMs.

Limitations and Future Work

This study was based on a small initial sample of pilot sites of varying sizes and, as such, may not reflect the experience of all VHA GPMs. In addition, the use of snowball sampling, while facilitating identification of key stakeholders, may introduce bias in participant sampling. Nonetheless, the results from this study provide findings that informed the national VHA GPM initiative and can inform further studies of practice management roles outside of the VA.

Further study of the VHA GPM implementation and similar roles in other health care systems is needed. As the GPM position is fully implemented across the VHA, large scale evaluation is needed to gain a more representative picture and allow for comparison of the GPM role at various types of facilities (eg, size, rurality, complexity, ranking based on access performance metrics).

Conclusion

Improving access to care is a central goal for health care systems. The incorporation of the GPM role is an innovative approach to improve access management strategies. Early study of prototype sites provided VHA leadership with valuable insights used to influence further rollout of this initiative. Based on our findings, national and local support are important to ongoing success. National access mandates, training, and resources should focus on ensuring sufficient GPM authority, enabling GPMs to use data, and ensuring GPMs engage with frontline clinical and administrative staff to improve veteran access to care.

The Veterans Health Administration (VHA) provides care for 9 million veterans at 1,255 health care sites linked to one of 170 local medical systems.¹ Recognizing that providing timely care requires effective access management, the US Congress mandated training of VHA staff to manage and improve access to care but did not provide additional local funds for new positions.² In response, the VHA created the group practice manager (GPM), a new position responsible for improving clinical practice management and unifying access improvement across leadership levels, professions, and services within each local medical system.

In May 2015, the VHA began hiring and training GPMs to spearhead management of access to services. The US Department of Veterans Affairs (VA) Office of Veteran Access to Care spearheaded GPM training, including face-to-face sessions, national calls, webinars, and educational materials. Five local medical systems were selected by the VA Office of Veteran Access to Care to implement the GPM role to allow for an early evaluation of the program that would inform a subsequent nationwide rollout. Implementation of the GPM role remained in the hands of local medical systems.

Longer wait times are shown to impact patient health.^3,4 Open access scheduling and other patient-centered access management interventions have been shown to improve availability of primary care appointments.⁵ However, little empirical evidence exists regarding the managers who focus on clinic access interventions. While the nonpeer-reviewed literature includes references to such roles, including GPMs, the empirical literature has focused on external practice faciliators,^6-8 “mid-level managers,”⁹ and clinic staff.¹⁰ We found no peer-reviewed articles on the needs and experiences of practice managers who are focused on improving access. The purpose of this study was to examine GPM prototype sites to both enhance subsequent nationwide implementation and to advance empirical literature on managing patient access within health care.

Methods

In 2015, the VA identified 5 prototype sites representing diverse geographic locations, size, and complexity for the implementation of the GPM role (Table 1). These sites self-identified as having clinical practice management experience. GPMs attended 4 training sessions between February and August 2015.

Data Collection

Participants from each prototype site included GPMs, national trainers, clinic leaders, and frontline staff. Table 2 includes the roles and sample size. Participants were recruited through purposive sampling followed by snowball sampling until thematic saturation was reached (the point at which subsequent data fail to produce new findings across sites and roles of interest).

Guided by the Consolidated Framework for Implementation Research (CFIR), the research team developed semistructured interview guides tailored to participants’ roles to elicit rich descriptions regarding overall impressions, practice management strategies, goals, activities, relationship to clinic roles, data analytics usage, challenges, barriers, and facilitators.¹¹ These guides included open-ended questions and structured prompts utilizing participant language for follow-up probes to minimize interviewing bias (eAppendix:

Data Analysis

Data were analyzed using iterative deductive and inductive content analysis.¹² Deductive content analysis consisted of identifying quotes that fit within preidentified categories (ie, perceptions of national effort, organizational structure for GPM, challenges, facilitators, metrics and tools, and mobilizing access culture) developed by the interdisciplinary research team. Further content analysis entailed open-coding and iteratively revisiting and reconciling codes associated within each preidentified category as new codes emerged. The team analyzed the resulting codes to inductively and iteratively identify and stabilize themes regarding the GPM role: roles and tasks, GPM characteristics, issues, and challenges. Through this process we moved coded data to reconciled descriptions suited to addressing the purposes of this study. Dedoose 7.0.23 software was used for qualitative data management and analysis.

Results

The study identified participants’ overall impressions of the GPM initiative and key themes within 4 major domains regarding implementing the GPM role: roles and tasks (implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff); GPM characteristics (familiarity with clinical services, knowledge of VHA systems, ability to analyze patient data, communication skills, and the ability to work with others); and issues, and challenges (technical, social, and structural).

Overall Impressions

Interviewees perceived the GPM initiative as a consolidation of existing distributed responsibilities into one role that directly reported to local top-level management with indirect reporting to national leaders. Many of the sites reported that they had designated or planned to designate a role resembling the GPM prior to the initiative. “There are staff who’ve been doing some of this work all along,” a GPM noted. “We just didn’t have them grouped together. They weren’t necessarily all working in the same type of service under the same type of structure.”

Whether the GPM position was new or not, participants referenced the importance and challenges of engaging the local facility in recognizing the agency associated with the GPM position. According to national support, the staff are trying to get the facility to understand “why the group practice manager is so important… we’ve got to embed that standard position in the system.”

While the GPM was recognized as the hub of access management, respondents recognized that transformation regarding access involved many players. “We have to create [an] orchestrated team inside each facility,” an advisor argued.

Respondents discussed how the initiative allows local facilities to appoint a specific person with a specific title and role who helps facilitate, organize, and legitimize an access focus at their sites. One GPM interviewee noted how the initiative helped refocus some of their previously less centralized efforts. “We’ve always looked at productivity; we’ve always looked at access; we’ve always looked at efficiency. I think the bigger difference is now there are individuals identified in the clinics, as practice managers as well…I interact with them. They interact with individual clinic staff, and it’s more of a group process than a single individual.”

The value of having tools available and being able to track and manage patient care as a specific example of the positive impact of this new role was noted by participants. A GPM noted that many health care providers will be happy to have tools to better manage their services and a process “that flows from a service level all the way up to executive management, where there is a common interest in making those things happen—I think that’s going to be a tremendous help.”

Participants expressed concern that the national GPM rollout would be a one-size-fits-all approach. These respondents emphasized the need to have the flexibility to customize their activities to meet their unique site and patient needs.

GPM Roles and Tasks

Participants described 4 primary roles that the GPM was expected to fill: implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff. Some activities overlapped in that they served to support multiple role areas (Figure 1).

Implementing clinic practice management. In the early stages of the initiative, the GPM’s primary role was to prepare the facility to implement a standardized set of clinic practice management (CPM) team processes. Part of standardizing the CPM process was defining the scope and tasks of the GPM, which requires significant planning for the implementation. “My big job is to finalize what we think group practice management is going to look [like] here,” a GPM reported.

Each prototype site had latitude to interpret the GPM initiative in a way that would work in their context within given VHA boundaries and ongoing initiatives. To achieve the high-level vision and purpose, the GPM first had to develop action plans that accounted for the operating environment of the facility. According to one GPM, VA national officials are “constantly” asking for action plans, which required significant time by specific deadlines. “They want an action plan [and to] clean up all your consults, [and to] clean up all your recall reminders.”

Leading on improving access efforts. Participants saw the GPM as the central staff member responsible for providing oversight of any activities and people involved in improving access. “I ensure everybody is doing what they’re supposed to do,” one GPM reported. When the GPM sees areas that are not being addressed, the individual tries to develop a process or training to “close those gaps.”

GPMs promoted an awareness of their goals, changes in process, and new tools accompanying the initiative. However, other access initiatives were occurring simultaneously creating confusion for health care providers and patients; thus GPMs found they were managing a wide array of related initiatives.

GPMs have to negotiate with leaders across the VHA facility, many of whom operated at a higher leadership level and had different priorities, to address access problems.

“I’m a lieutenant as a GPM in a clinic, a GPM noted. “How is the lieutenant going to talk to a major or a colonel in the clinic and say your clinic has problems. How[‘s] that lieutenant...going to do that? With people skills!”

Managing expectations about the speed and to what extent a problem could be resolved was an important part of the GPM leadership role. “I see myself as managing expectations both up to the leadership and down to the frontline,” a GPM explained. “I find myself talking to leadership [about] our progress. But at the same time, we have to say, ‘not everything can be fixed overnight.’”

Providing leadership on access-related issues included developing a range of options for addressing patient access problems. One analytics manager recounted how the GPM role led to evaluating how physical space limited efficiency in clinic flow. The first step was identifying possible additional rooms to improve clinic flow. This required working with the space committee to “get someone to look at our overarching space and find someplace else for them to sit” to avoid adding to congestion in the clinic area.
 

Supporting data analytics. Given the importance of data analytics, GPMs had a critical role in helping to ensure that the data were accurate and clean. At one facility the GPM and the business managers, “are doing a tremendous amount to clean up our data to make it accurately reflect what it is that we’re doing,” reported a community clinic director.

GPMs routinely immersed themselves in the data to understand access issues. GPMs worked with clinic leaders to identify the underlying causes and various solutions. The GPMs maintained access through administrative scrubbing of the data and finding “smart ways to get patients scheduled,” a GPM explained. “I don’t think our facility would have taken care of as many veterans in the time frame as we did....We’ve cleared over 4,000 consults that were older than 90 days. We have cleared thousands and thousands of weekly reminders.”

GPMs expressed the need for aggregated (ie, dashboard) and standardized information to efficiently address access issues. “I would like to have some more standardization on what’s being reviewed; it seems to change frequently, and so [to] be able to track and trend and have something given to me to review,” one health care provider requested. On the other hand, participants also described a need for decision support tools that would lead to action aligned with best practices. “Instead of a dashboard or something that’s just measuring their performance, it’s more something that they can look at and take action” a national support staff advisor suggested.

Enabling self and staff. GPMs felt they were most effective if they enabled themselves and stakeholders through training and by cultivating relationships and team building. Figure 2 illustrates the various stakeholders GPMs reported engaging with. The GPMS should be building relationships, bridging relationships, developing trust, and then providing a higher level of hands-on management. However, “that doesn’t really happen right now, day to day,” one member of leadership reported.

Key topics in GPM leadership training included both soft skills (change management, culture change, and negotiation skills) and crucial analytic/technical training (understanding each metric and dashboard available, data analytics, and supply/demand balancing techniques). The GPMs not only wanted to understand metrics as part of their training, but also want to know what to do about them.

An “operationalization” training approach (discerning the meaning of data, data-based decision making, and determining action from multiple options) inspired by real-life situations was preferred by participants. Other effective learning structures included job aids in the form of templated Gantt charts, process maps to guide GPMs through implementation of new processes, formalized peer learning (accumulated field insights shared during training courses), and informal peer sharing of direct experiences during calls.

GPMs also emphasized training for frontline clinical and support staff, including schedulers. VHA schedulers typically have less education and experience higher turnover rates than do other clinic staff, yet they carry out complex and critical tasks. Providing training and ensuring that any materials developed for training and education were appropriate to the level of education of schedulers was an important task for GPMs. “If they don’t understand all of the scheduling principles and potential,” one GPM explained, “we will not be maximizing the utilization of our parts.”

GPMs also provided informal education to clinicians. Participants noted GPMs have to avoid appearing to overstep their positions or presuming more knowledge and expertise than clinicians. They “have to be able to teach a physician without being overbearing, in a way a physician will accept it as advisement,” one program leader reported.
 

GPM knowledge, skills, and abilities. GPMs presented a complex range of knowledge, skills, and abilities, including clinical, administrative, analytics, and people skills. All interviewees reported that their prior education and experience did not sufficiently train them for the GPM role. GPMs identified a willingness to learn quickly as a critical characteristic. Many GPMs tended to have a formal education in health administration or business (eg, MBAs); others had administrative experience (eg, administrative assistance to executive leadership) or clinical training (eg, physician assistant). Detailed clinical knowledge was not expected, but clinical familiarity was helpful.

Some interviewees also mentioned previous experience and familiarity with the VHA system specifically as an advantage. This was especially true for VA outpatient flows, clinic flows, and understanding what an outpatient is in a VA context. Interviewees noted the importance of GPMs needing to be able to analyze patient demand metrics and underlying data in order to determine supply of providers and then to allocate adequate resources to complement providers. Forecasting skills were referenced as a key point. “They need to be able to be assured that they can recruit more providers if needed,” a national support staff advisor noted.

Given the importance of developing effective relationships, communication skills were mentioned by most participants and underscored as critical to establishing trust between GPMs and others as the initiative was being implemented. Interviewees indicated that relationship building was further enhanced when GPMs possessed the ability to “work with” rather than command clinicians and staff; navigate politics; and were respectful of other people’s knowledge, skills, abilities, and status. “They have to work with the nursing staff and teach them,” a leader described, “so that people understand that we are going to a different place to achieve our primary objectives and goals.”

Issues and Challenges

Participants identified several technical, social, and structural challenges and barriers to successfully implementing the GPM role.

Technical challenges. Recurring themes across all phases of data analytics were GPMs’ capability to challenge data use and use large volumes of information from multiple data sources (entering and accessing data; “drilling down” from summaries; generating reports; and analyzing and interpreting resulting metrics). Interviewees reported that information assessment and analytic support were not consistent. One GPM had a data analyst pulling reports needed to support clinical units while other GPMs trained staff to pull data. Even with support, some GPMs had issues due to limited information technology (IT) skills or access privileges leading to inefficiencies and delays. “Whenever I need anything from a programmer, I have to go through, you know, the IT gods in the sky,” one GPM remarked. “That usually takes a few months or more.”

Social challenges. Instituting the GPM role was a cultural change, and interviewees reported needing to address resistance to CPM model efforts. Resistance to change “is particularly hard in the VA just because it has a unique culture,” one leader noted. “There is a comfort in the legacy way of doing things.” The GPM initiative was introduced during a time when other national level initiatives were being implemented throughout the VHA. Fulfilling requests for information for these initiatives became the responsibility of the GPM and their team, which diverted attention from the mandate to improve access. Furthermore, GPMs were often considered the “change communicators” to clinics putting them in the role of “bad messenger,” which degraded trust and made it difficult to partner with clinicians.

Efforts to work through change management and build relationships included general program awareness presentation to internal stakeholders; including key stakeholders in GPM committees; pre-emptive conversations with unit chiefs; creating awareness of the GPM activities and progress through formal and informal update meetings; and identifying successes regarding access.

Structural challenges. The GPM role did not have direct supervision over clinical and administrative leaders, making it challenging to enact change. GPMs reported that “they do not always have authority over the area that they are being asked to manage,” which made their work difficult, requiring strong negotiation skills and political savvy to affect change. However, as the clinic staff and providers saw how the GPM could support and positively impact their practice, these challenges began to subside.

Discussion

This study provides empirical evidence regarding the implementation of a new access management strategy for health care systems focused on improving timeliness of care. First, the GPM position was seen as critical at each facility, as a single point person, to help local system leaders respond effectively to both national mandates and local context. Second, requiring the GPMs to report to the medical center director or chief of staff was important for integrating access perspectives across service lines and to facilitate a strong GPM role in strategic planning. Third, the intentional flexibility of the access management initiative, beyond the nationally specified aspects of the GPM role, was key for allowing individual sites to adapt to unique local challenges, resources, and population demands. Fourth, the initiative provided GPMs with opportunities to learn important skills and support the acquisition, utilization, and communication of a tremendous range of data toward responsive action.

According to our respondents, the GPM role demands functioning across a broad set of responsibilities; understanding the big picture as well as the complex underlying variables; engaging facility leaders, clinical and administrative staff; and prioritizing competing national and local demands. Consistent with previous findings, effective GPMs must possess a complex set of skills (interpersonal, analytic, and leadership) and the ability to create a supporting team.¹³

In practice, improving access at individual sites of care (VA medical centers and community-based outpatient clinics) poses significant challenges, especially in the early stages, even with the assistance of a GPM. For example, some respondents reported being overwhelmed by the volume of available data and dashboards, and responding to current requests for data analysis and dissemination sometimes impeded long range planning. Multiple national access-related initiatives and local pressures also generated excessive and potentially conflicting demands. Thus, while the creation of a GPM position seemed to be essential for the pilot sites to improve local access and timeliness to care, success also requires ongoing national and facility-wide communication, education, and support. Ongoing data analysis training and support will be critical to ensuring the sustainability of the position. Last, recruiting GPMs with the needed complex skill set may prove to be challenging, and it will be important to provide resources to identify, attract, and retain well-qualified GPMs.

Limitations and Future Work

This study was based on a small initial sample of pilot sites of varying sizes and, as such, may not reflect the experience of all VHA GPMs. In addition, the use of snowball sampling, while facilitating identification of key stakeholders, may introduce bias in participant sampling. Nonetheless, the results from this study provide findings that informed the national VHA GPM initiative and can inform further studies of practice management roles outside of the VA.

Further study of the VHA GPM implementation and similar roles in other health care systems is needed. As the GPM position is fully implemented across the VHA, large scale evaluation is needed to gain a more representative picture and allow for comparison of the GPM role at various types of facilities (eg, size, rurality, complexity, ranking based on access performance metrics).

Conclusion

Improving access to care is a central goal for health care systems. The incorporation of the GPM role is an innovative approach to improve access management strategies. Early study of prototype sites provided VHA leadership with valuable insights used to influence further rollout of this initiative. Based on our findings, national and local support are important to ongoing success. National access mandates, training, and resources should focus on ensuring sufficient GPM authority, enabling GPMs to use data, and ensuring GPMs engage with frontline clinical and administrative staff to improve veteran access to care.

The Veterans Health Administration (VHA) provides care for 9 million veterans at 1,255 health care sites linked to one of 170 local medical systems.¹ Recognizing that providing timely care requires effective access management, the US Congress mandated training of VHA staff to manage and improve access to care but did not provide additional local funds for new positions.² In response, the VHA created the group practice manager (GPM), a new position responsible for improving clinical practice management and unifying access improvement across leadership levels, professions, and services within each local medical system.

In May 2015, the VHA began hiring and training GPMs to spearhead management of access to services. The US Department of Veterans Affairs (VA) Office of Veteran Access to Care spearheaded GPM training, including face-to-face sessions, national calls, webinars, and educational materials. Five local medical systems were selected by the VA Office of Veteran Access to Care to implement the GPM role to allow for an early evaluation of the program that would inform a subsequent nationwide rollout. Implementation of the GPM role remained in the hands of local medical systems.

Longer wait times are shown to impact patient health.^3,4 Open access scheduling and other patient-centered access management interventions have been shown to improve availability of primary care appointments.⁵ However, little empirical evidence exists regarding the managers who focus on clinic access interventions. While the nonpeer-reviewed literature includes references to such roles, including GPMs, the empirical literature has focused on external practice faciliators,^6-8 “mid-level managers,”⁹ and clinic staff.¹⁰ We found no peer-reviewed articles on the needs and experiences of practice managers who are focused on improving access. The purpose of this study was to examine GPM prototype sites to both enhance subsequent nationwide implementation and to advance empirical literature on managing patient access within health care.

Methods

In 2015, the VA identified 5 prototype sites representing diverse geographic locations, size, and complexity for the implementation of the GPM role (Table 1). These sites self-identified as having clinical practice management experience. GPMs attended 4 training sessions between February and August 2015.

Data Collection

Participants from each prototype site included GPMs, national trainers, clinic leaders, and frontline staff. Table 2 includes the roles and sample size. Participants were recruited through purposive sampling followed by snowball sampling until thematic saturation was reached (the point at which subsequent data fail to produce new findings across sites and roles of interest).

Guided by the Consolidated Framework for Implementation Research (CFIR), the research team developed semistructured interview guides tailored to participants’ roles to elicit rich descriptions regarding overall impressions, practice management strategies, goals, activities, relationship to clinic roles, data analytics usage, challenges, barriers, and facilitators.¹¹ These guides included open-ended questions and structured prompts utilizing participant language for follow-up probes to minimize interviewing bias (eAppendix:

Data Analysis

Data were analyzed using iterative deductive and inductive content analysis.¹² Deductive content analysis consisted of identifying quotes that fit within preidentified categories (ie, perceptions of national effort, organizational structure for GPM, challenges, facilitators, metrics and tools, and mobilizing access culture) developed by the interdisciplinary research team. Further content analysis entailed open-coding and iteratively revisiting and reconciling codes associated within each preidentified category as new codes emerged. The team analyzed the resulting codes to inductively and iteratively identify and stabilize themes regarding the GPM role: roles and tasks, GPM characteristics, issues, and challenges. Through this process we moved coded data to reconciled descriptions suited to addressing the purposes of this study. Dedoose 7.0.23 software was used for qualitative data management and analysis.

Results

The study identified participants’ overall impressions of the GPM initiative and key themes within 4 major domains regarding implementing the GPM role: roles and tasks (implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff); GPM characteristics (familiarity with clinical services, knowledge of VHA systems, ability to analyze patient data, communication skills, and the ability to work with others); and issues, and challenges (technical, social, and structural).

Overall Impressions

Interviewees perceived the GPM initiative as a consolidation of existing distributed responsibilities into one role that directly reported to local top-level management with indirect reporting to national leaders. Many of the sites reported that they had designated or planned to designate a role resembling the GPM prior to the initiative. “There are staff who’ve been doing some of this work all along,” a GPM noted. “We just didn’t have them grouped together. They weren’t necessarily all working in the same type of service under the same type of structure.”

Whether the GPM position was new or not, participants referenced the importance and challenges of engaging the local facility in recognizing the agency associated with the GPM position. According to national support, the staff are trying to get the facility to understand “why the group practice manager is so important… we’ve got to embed that standard position in the system.”

While the GPM was recognized as the hub of access management, respondents recognized that transformation regarding access involved many players. “We have to create [an] orchestrated team inside each facility,” an advisor argued.

Respondents discussed how the initiative allows local facilities to appoint a specific person with a specific title and role who helps facilitate, organize, and legitimize an access focus at their sites. One GPM interviewee noted how the initiative helped refocus some of their previously less centralized efforts. “We’ve always looked at productivity; we’ve always looked at access; we’ve always looked at efficiency. I think the bigger difference is now there are individuals identified in the clinics, as practice managers as well…I interact with them. They interact with individual clinic staff, and it’s more of a group process than a single individual.”

The value of having tools available and being able to track and manage patient care as a specific example of the positive impact of this new role was noted by participants. A GPM noted that many health care providers will be happy to have tools to better manage their services and a process “that flows from a service level all the way up to executive management, where there is a common interest in making those things happen—I think that’s going to be a tremendous help.”

Participants expressed concern that the national GPM rollout would be a one-size-fits-all approach. These respondents emphasized the need to have the flexibility to customize their activities to meet their unique site and patient needs.

GPM Roles and Tasks

Participants described 4 primary roles that the GPM was expected to fill: implementing clinic practice management, leading patient access, supporting data analytics, and enabling self and staff. Some activities overlapped in that they served to support multiple role areas (Figure 1).

Implementing clinic practice management. In the early stages of the initiative, the GPM’s primary role was to prepare the facility to implement a standardized set of clinic practice management (CPM) team processes. Part of standardizing the CPM process was defining the scope and tasks of the GPM, which requires significant planning for the implementation. “My big job is to finalize what we think group practice management is going to look [like] here,” a GPM reported.

Each prototype site had latitude to interpret the GPM initiative in a way that would work in their context within given VHA boundaries and ongoing initiatives. To achieve the high-level vision and purpose, the GPM first had to develop action plans that accounted for the operating environment of the facility. According to one GPM, VA national officials are “constantly” asking for action plans, which required significant time by specific deadlines. “They want an action plan [and to] clean up all your consults, [and to] clean up all your recall reminders.”

Leading on improving access efforts. Participants saw the GPM as the central staff member responsible for providing oversight of any activities and people involved in improving access. “I ensure everybody is doing what they’re supposed to do,” one GPM reported. When the GPM sees areas that are not being addressed, the individual tries to develop a process or training to “close those gaps.”

GPMs promoted an awareness of their goals, changes in process, and new tools accompanying the initiative. However, other access initiatives were occurring simultaneously creating confusion for health care providers and patients; thus GPMs found they were managing a wide array of related initiatives.

GPMs have to negotiate with leaders across the VHA facility, many of whom operated at a higher leadership level and had different priorities, to address access problems.

“I’m a lieutenant as a GPM in a clinic, a GPM noted. “How is the lieutenant going to talk to a major or a colonel in the clinic and say your clinic has problems. How[‘s] that lieutenant...going to do that? With people skills!”

Managing expectations about the speed and to what extent a problem could be resolved was an important part of the GPM leadership role. “I see myself as managing expectations both up to the leadership and down to the frontline,” a GPM explained. “I find myself talking to leadership [about] our progress. But at the same time, we have to say, ‘not everything can be fixed overnight.’”

Providing leadership on access-related issues included developing a range of options for addressing patient access problems. One analytics manager recounted how the GPM role led to evaluating how physical space limited efficiency in clinic flow. The first step was identifying possible additional rooms to improve clinic flow. This required working with the space committee to “get someone to look at our overarching space and find someplace else for them to sit” to avoid adding to congestion in the clinic area.
 

Supporting data analytics. Given the importance of data analytics, GPMs had a critical role in helping to ensure that the data were accurate and clean. At one facility the GPM and the business managers, “are doing a tremendous amount to clean up our data to make it accurately reflect what it is that we’re doing,” reported a community clinic director.

GPMs routinely immersed themselves in the data to understand access issues. GPMs worked with clinic leaders to identify the underlying causes and various solutions. The GPMs maintained access through administrative scrubbing of the data and finding “smart ways to get patients scheduled,” a GPM explained. “I don’t think our facility would have taken care of as many veterans in the time frame as we did....We’ve cleared over 4,000 consults that were older than 90 days. We have cleared thousands and thousands of weekly reminders.”

GPMs expressed the need for aggregated (ie, dashboard) and standardized information to efficiently address access issues. “I would like to have some more standardization on what’s being reviewed; it seems to change frequently, and so [to] be able to track and trend and have something given to me to review,” one health care provider requested. On the other hand, participants also described a need for decision support tools that would lead to action aligned with best practices. “Instead of a dashboard or something that’s just measuring their performance, it’s more something that they can look at and take action” a national support staff advisor suggested.

Enabling self and staff. GPMs felt they were most effective if they enabled themselves and stakeholders through training and by cultivating relationships and team building. Figure 2 illustrates the various stakeholders GPMs reported engaging with. The GPMS should be building relationships, bridging relationships, developing trust, and then providing a higher level of hands-on management. However, “that doesn’t really happen right now, day to day,” one member of leadership reported.

Key topics in GPM leadership training included both soft skills (change management, culture change, and negotiation skills) and crucial analytic/technical training (understanding each metric and dashboard available, data analytics, and supply/demand balancing techniques). The GPMs not only wanted to understand metrics as part of their training, but also want to know what to do about them.

An “operationalization” training approach (discerning the meaning of data, data-based decision making, and determining action from multiple options) inspired by real-life situations was preferred by participants. Other effective learning structures included job aids in the form of templated Gantt charts, process maps to guide GPMs through implementation of new processes, formalized peer learning (accumulated field insights shared during training courses), and informal peer sharing of direct experiences during calls.

GPMs also emphasized training for frontline clinical and support staff, including schedulers. VHA schedulers typically have less education and experience higher turnover rates than do other clinic staff, yet they carry out complex and critical tasks. Providing training and ensuring that any materials developed for training and education were appropriate to the level of education of schedulers was an important task for GPMs. “If they don’t understand all of the scheduling principles and potential,” one GPM explained, “we will not be maximizing the utilization of our parts.”

GPMs also provided informal education to clinicians. Participants noted GPMs have to avoid appearing to overstep their positions or presuming more knowledge and expertise than clinicians. They “have to be able to teach a physician without being overbearing, in a way a physician will accept it as advisement,” one program leader reported.
 

GPM knowledge, skills, and abilities. GPMs presented a complex range of knowledge, skills, and abilities, including clinical, administrative, analytics, and people skills. All interviewees reported that their prior education and experience did not sufficiently train them for the GPM role. GPMs identified a willingness to learn quickly as a critical characteristic. Many GPMs tended to have a formal education in health administration or business (eg, MBAs); others had administrative experience (eg, administrative assistance to executive leadership) or clinical training (eg, physician assistant). Detailed clinical knowledge was not expected, but clinical familiarity was helpful.

Some interviewees also mentioned previous experience and familiarity with the VHA system specifically as an advantage. This was especially true for VA outpatient flows, clinic flows, and understanding what an outpatient is in a VA context. Interviewees noted the importance of GPMs needing to be able to analyze patient demand metrics and underlying data in order to determine supply of providers and then to allocate adequate resources to complement providers. Forecasting skills were referenced as a key point. “They need to be able to be assured that they can recruit more providers if needed,” a national support staff advisor noted.

Given the importance of developing effective relationships, communication skills were mentioned by most participants and underscored as critical to establishing trust between GPMs and others as the initiative was being implemented. Interviewees indicated that relationship building was further enhanced when GPMs possessed the ability to “work with” rather than command clinicians and staff; navigate politics; and were respectful of other people’s knowledge, skills, abilities, and status. “They have to work with the nursing staff and teach them,” a leader described, “so that people understand that we are going to a different place to achieve our primary objectives and goals.”

Issues and Challenges

Participants identified several technical, social, and structural challenges and barriers to successfully implementing the GPM role.

Technical challenges. Recurring themes across all phases of data analytics were GPMs’ capability to challenge data use and use large volumes of information from multiple data sources (entering and accessing data; “drilling down” from summaries; generating reports; and analyzing and interpreting resulting metrics). Interviewees reported that information assessment and analytic support were not consistent. One GPM had a data analyst pulling reports needed to support clinical units while other GPMs trained staff to pull data. Even with support, some GPMs had issues due to limited information technology (IT) skills or access privileges leading to inefficiencies and delays. “Whenever I need anything from a programmer, I have to go through, you know, the IT gods in the sky,” one GPM remarked. “That usually takes a few months or more.”

Social challenges. Instituting the GPM role was a cultural change, and interviewees reported needing to address resistance to CPM model efforts. Resistance to change “is particularly hard in the VA just because it has a unique culture,” one leader noted. “There is a comfort in the legacy way of doing things.” The GPM initiative was introduced during a time when other national level initiatives were being implemented throughout the VHA. Fulfilling requests for information for these initiatives became the responsibility of the GPM and their team, which diverted attention from the mandate to improve access. Furthermore, GPMs were often considered the “change communicators” to clinics putting them in the role of “bad messenger,” which degraded trust and made it difficult to partner with clinicians.

Efforts to work through change management and build relationships included general program awareness presentation to internal stakeholders; including key stakeholders in GPM committees; pre-emptive conversations with unit chiefs; creating awareness of the GPM activities and progress through formal and informal update meetings; and identifying successes regarding access.

Structural challenges. The GPM role did not have direct supervision over clinical and administrative leaders, making it challenging to enact change. GPMs reported that “they do not always have authority over the area that they are being asked to manage,” which made their work difficult, requiring strong negotiation skills and political savvy to affect change. However, as the clinic staff and providers saw how the GPM could support and positively impact their practice, these challenges began to subside.

Discussion

This study provides empirical evidence regarding the implementation of a new access management strategy for health care systems focused on improving timeliness of care. First, the GPM position was seen as critical at each facility, as a single point person, to help local system leaders respond effectively to both national mandates and local context. Second, requiring the GPMs to report to the medical center director or chief of staff was important for integrating access perspectives across service lines and to facilitate a strong GPM role in strategic planning. Third, the intentional flexibility of the access management initiative, beyond the nationally specified aspects of the GPM role, was key for allowing individual sites to adapt to unique local challenges, resources, and population demands. Fourth, the initiative provided GPMs with opportunities to learn important skills and support the acquisition, utilization, and communication of a tremendous range of data toward responsive action.

According to our respondents, the GPM role demands functioning across a broad set of responsibilities; understanding the big picture as well as the complex underlying variables; engaging facility leaders, clinical and administrative staff; and prioritizing competing national and local demands. Consistent with previous findings, effective GPMs must possess a complex set of skills (interpersonal, analytic, and leadership) and the ability to create a supporting team.¹³

In practice, improving access at individual sites of care (VA medical centers and community-based outpatient clinics) poses significant challenges, especially in the early stages, even with the assistance of a GPM. For example, some respondents reported being overwhelmed by the volume of available data and dashboards, and responding to current requests for data analysis and dissemination sometimes impeded long range planning. Multiple national access-related initiatives and local pressures also generated excessive and potentially conflicting demands. Thus, while the creation of a GPM position seemed to be essential for the pilot sites to improve local access and timeliness to care, success also requires ongoing national and facility-wide communication, education, and support. Ongoing data analysis training and support will be critical to ensuring the sustainability of the position. Last, recruiting GPMs with the needed complex skill set may prove to be challenging, and it will be important to provide resources to identify, attract, and retain well-qualified GPMs.

Limitations and Future Work

This study was based on a small initial sample of pilot sites of varying sizes and, as such, may not reflect the experience of all VHA GPMs. In addition, the use of snowball sampling, while facilitating identification of key stakeholders, may introduce bias in participant sampling. Nonetheless, the results from this study provide findings that informed the national VHA GPM initiative and can inform further studies of practice management roles outside of the VA.

Further study of the VHA GPM implementation and similar roles in other health care systems is needed. As the GPM position is fully implemented across the VHA, large scale evaluation is needed to gain a more representative picture and allow for comparison of the GPM role at various types of facilities (eg, size, rurality, complexity, ranking based on access performance metrics).

Conclusion

Improving access to care is a central goal for health care systems. The incorporation of the GPM role is an innovative approach to improve access management strategies. Early study of prototype sites provided VHA leadership with valuable insights used to influence further rollout of this initiative. Based on our findings, national and local support are important to ongoing success. National access mandates, training, and resources should focus on ensuring sufficient GPM authority, enabling GPMs to use data, and ensuring GPMs engage with frontline clinical and administrative staff to improve veteran access to care.