Veterans Affairs & Military Medicine Outlook Fall 2017 by Faircount Media Group

INTERVIEWS David J. Shulkin, M.D.

Secretary of the Department of Veterans Affairs

Sen. Jon Tester

Ranking Member of the Senate Committee on Veterans’ Affairs

Rep. Phil Roe, M.D.

Chairman, House Committee on Veterans’ Affairs

Linda McConnell

Chief Nursing Officer, VA Office of Nursing Services

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

TABLE OF CONTENTS INTERVIEWS

David J. Shulkin, M.D.

Sen. Jon Tester

Rep. Phil Roe, M.D.

Linda McConnell

By Chuck Oldham

By Rhonda Carpenter

Secretary of the Department of Veterans Affairs

Ranking Member of the Senate Committee on Veterans’ Affairs

Chairman, House Committee on Veterans’ Affairs

Chief Nursing Officer, VA Office of Nursing Services

FEATURES

WOUND CARE AND HEALING

Aiming for zero preventable deaths By Craig Collins

THE NATIONAL CENTER FOR PTSD

At the forefront of trauma research and education By Craig Collins

FORCE HEALTH PROTECTION

Battlefield medicine evolves beyond the battlefield. By Craig Collins

A NEW ERA IN HEPATITIS C TREATMENT

With a new class of drugs, VA’s clinicians are ramping up efforts to cure veterans of one of the most pernicious viral diseases. By Craig Collins

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Leadership, integrity, innovation

College of Graduate Health Studies Online

TABLE OF CONTENTS

Advance to the forefront of your profession.

FEATURES CONTINUED

PREVENTING AND TREATING HIV

DUKE UNIVERSITY PA PROGRAM AND THE NAVY CORPSMEN/VETERAN CONNECTION

By J.R. Wilson

Learn more at atsu.edu/advance

CHAPLAINS PLAY A KEY ROLE IN PROVIDING SPIRITUAL AND COMPREHENSIVE CARE By Charles Dervarics

CARDIOLOGY CARE ADVANCES IN THE VA

IVF FOR WOUNDED VETERANS

TARGETING CANCER

By Gail Gourley

A.T. Still University’s College of Graduate Health Studies offers online degrees in:

VA flexes its muscle – and leverages its many partnerships – to bring cutting-edge cancer care to a growing number of veterans.

Doctor of Education in Health Professions Doctor of Health Administration

By Craig Collins

Doctor of Health Sciences Master of Health Administration

DIABETES: A PERSONAL APPROACH

Master of Public Health

The VA and DOD’s new guidelines for managing diabetes ramp up a focus on the individual patient.

Master of Public Health-Dental Emphasis Master of Science in Kinesiology

By Craig Collins

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Published by Faircount Media Group 4915 West Cypress Street Tampa, FL 33607 Tel: 813.639.1900 www.defensemedianetwork.com www.faircount.com EDITORIAL Editor in Chief: Chuck Oldham Managing Editor: Ana E. Lopez Editor: Rhonda Carpenter Contributing Writers: Rhonda Carpenter, Craig Collins, Charles Dervarics, Gail Gourley, Chuck Oldham, J.R. Wilson DESIGN AND PRODUCTION Art Director: Robin K. McDowall Designer: Daniel Mrgan Ad Traffic Manager: Rebecca Laborde ADVERTISING Ad Sales Manager: K en Meyer Account Executives: Scott Ressler, Geoffrey Weiss OPERATIONS AND ADMINISTRATION Chief Operating Officer: Lawrence Roberts VP, Business Development: Robin Jobson Business Development: Damion Harte Financial Controller: Robert John Thorne Chief Information Officer: John Madden Business Analytics Manager: Colin Davidson FAIRCOUNT MEDIA GROUP Publisher: Ross Jobson

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

INTERVIEW

DAVID J. SHULKIN, M.D. Secretary of the Department of Veterans Affairs By Chuck Oldham

■■ David J. Shulkin, M.D., secretary of the Department of Veterans

Affairs.

Most Influential People in American Healthcare.” He has been married to his wife, Dr. Merle Bari, for more than 30 years. They are the parents of two grown children.

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PHOTO BY GENE RUSSELL

n The Honorable David J. Shulkin, M.D., was nominated by President Donald Trump to serve as the ninth secretary of the U.S. Department of Veterans Affairs (VA) and was confirmed by the United States Senate on Feb. 13, 2017. Prior to his confirmation as secretary, Shulkin served as VA’s under secretary for health for 18 months, leading the nation’s largest integrated health care system, with more than 1,200 sites of care serving nearly 9 million veterans. Before he began his service with VA, Shulkin held numerous chief executive roles at Morristown Medical Center and the Atlantic Health System Accountable Care Organization. He also served as president and CEO of Beth Israel Medical Center in New York City. Shulkin has held numerous physician leadership roles including chief medical officer of the University of Pennsylvania Health System, Temple University Hospital, and the Medical College of Pennsylvania Hospital. He has also held academic positions including chairman of medicine and vice dean at Drexel University School of Medicine. As an entrepreneur, Shulkin founded and served as chairman and CEO of DoctorQuality, one of the first consumer-oriented sources of information on quality and safety in health care. A board-certified internist, Shulkin is also a fellow of the American College of Physicians. He received his medical degree from the Medical College of Pennsylvania, and he completed his internship at Yale University School of Medicine and a residency and fellowship in general medicine at the University of Pittsburgh Presbyterian Medical Center. He also received advanced training in outcomes research and economics as a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania. Shulkin has been named as one of the “50 Most Influential Physician Executives in the Country” by Modern Healthcare. He has also previously been named among the “One Hundred

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Veterans Affairs & Military Medicine Outlook: How much has the scope of your responsibilities increased or changed as secretary of the Department of Veterans Affairs (VA) in comparison with your previous job as under secretary for health? David J. Shulkin, M.D.: The scope of the job is certainly to represent veterans on all issues, not just health care issues. So therefore, our responsibility to carry out our mission involves health care, of course, but the secretary’s role is to also make sure we’re doing the same type of job and services as it relates to all the benefits that veterans deserve – whether they are disability benefits, whether they are educational benefits, whether it’s home loans or other benefits that we offer. [The role also oversees] our national cemeteries, which [there] are about 170 of them throughout the country, and in addition, all the services that support all three administrations that report up to the secretary that include IT, human resources, finance, etc. So, it’s a much larger role and responsibility. The last time we spoke, you had five priorities for the Veterans Health Administration (VHA) that you were working on. Could you discuss your top five priorities for the VA as a whole? And are these similar to the ones you had at VHA? They are just like what we had talked about in the first question. They are somewhat broader in their scope than necessarily simply focusing in on health care alone, and while the five are different, there clearly is some continuity among the five. So, the five of them for the department are to broaden greater choice for veterans. And this one is not just for health care, but this really is allowing the veteran to be in the center of the decision-making. This is our overarching strategy that will allow us to evolve as an organization and become more customer focused. So, for health care, this may mean giving veterans more choice about where they get their care and how they get their care, whether it means being able to schedule appointments online from their mobile phones, whether it means giving them more choice out in the community and making that program less administratively complex and more appropriate for a clinical health system like we are, and really changing our policies to allow veterans more choice in the way that they get their care delivered. The second one is to improve the timeliness of our services. So, in VHA, I was focused on wait times for improving the timeliness of our services for the department; for health, that means, clearly, improving wait times, but we’re doing it somewhat differently. We’re doing it through a strategy of transparency. So, we publish all of our wait times

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■■ “When you’re committed to transparency – and we’ve really doubled down on that strategy to become the most transparent organization in government – what you end up finding is that sometimes you are telling the good news, but sometimes you’re not.”

now, and we update those on the website every week so veterans have an ability to see where we’re doing well and where we may not be doing as well so that they can make choices about where they are going to get their health care. Instead of just saying, “I’m sorry we don’t have anything available,” they can see where else in the country or where else in the region they might go. They can see whether they want to wait for that care or go out into the community. But for disability, that means increasing the timeliness of the disability payments, and we are focused on reducing the wait times for that. For appeals, that means decreasing the time that it takes to get a decision on an appeal if a veteran files an appeal. The third focus of VA is to focus our resources more appropriately, and that means that we can’t invest in everything equally. So … we’ve worked with our veteran groups to get the feedback to determine what are really services that are critical to veterans and what does VA do uniquely for veterans that [is] focused on serving those that were injured or disabled in their tours of duty. So, we have come up with a set of what we call foundational services. They are things like polytrauma, traumatic brain injury, the treatment of PTSD, blind rehabilitation, orthotics prosthetics, spinal cord injury [for which] we are really making sure that we are developing worldclass services. So, it means putting more dollars into them, more management attention into them, and really improving our services. The fourth area is to modernize our systems, and that means that we are focused on improving the facilities and the technology that we’re using to support our veterans. So, I’ve recently announced that we have 1,100 facilities that are either underutilized or vacant that we’ll be disposing of to reinvest in those facilities where veterans are being serviced. I’ve announced a new electronic medical record to modernize our IT systems. Our accountability log gives us new management techniques. So, we’re 9

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VA PHOTO BY ROBERT TURTIL

modernizing our human resources authorities to be able to make sure the right people are working in VA. So, we are really aggressively trying to modernize the VA. And the last of the strategies is my only clinical priority and that is to reduce veteran suicide. So that has really been a major focus of ours since I became secretary – to make sure that we are reducing suicides. So, you’ve seen announcements such as that we’re providing emergency mental health care to other-than-honorably discharged. We’ve dramatically improved our hiring in the veterans’ crisis line so we’re answering many more calls and answering those in a more timely fashion. We’re trying to add a thousand new mental health professionals throughout the VA. So [it’s] a number of things that we are focused on to address that last priority. Were there any particular issues you discovered while leading VHA that you can now more effectively address in your new position? I think the clearest example and the biggest change that I saw from under secretary to secretary was this real focus on transparency and sharing information with the outside world. So, our publishing of wait times, our

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■■ VA Secretary Dr. David Shulkin hosts a meeting of robotics experts

in Washington for a VA Robotics in Healthcare Roundtable on June 27, 2017. The meeting brought together a select group of subjectmatter experts in the health care robotics field across industry and academia. The purpose of the event was to understand the current robotics landscape, the pipeline of developing capabilities, and the trends driving new inventions and market development as VA strives to enhance its foundational services for veterans. The event’s end goal was to create a short- and long-term strategy that outlines future directions to support veterans and next steps in developing a robust robotics practice in VA.

publishing now of data on quality that compares the VA to private-sector hospitals and health care are focused on … our disciplinary actions so that people know that we are taking the issue of accountability and disciplinary actions very seriously. We just recently started publishing our settlements that we’ve made with employees. So, I think that that is the biggest change that ref lects my belief that we have to make sure that everybody understands that we have heard the feedback. We’ve recognized 11

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

the failures that we’ve had in the past, and the way to move forward is to not only act swiftly and boldly, but do it in a way that we’re sharing exactly what we are doing with the public. It seems like it enables you as well to tell the good news story, because even though the media to some extent focused on things like wait times, veterans – as far as their care is concerned – overall seem to be extremely pleased with the quality of care they get in VA facilities. Well, we publish the veterans’ satisfaction scores publicly as well. And we show those comparisons to private-sector institutions. When you’re committed to transparency – and we’ve really doubled down on that strategy to become the most transparent organization in government – what you end up finding is that sometimes you are telling the good news, but sometimes you’re not. And in a system as large as ours, with locations all across the country and even beyond, you have everything. So, you have the picture where it’s really working well and actually much better than the private sector or our wait times are well below and our satisfaction is well above the private sector, and then you have places where it really isn’t working well. And that’s what you have to focus on. So, if you looked at our wait times in Guam, they’re horrific. And we have to find different strategies to address that, but as you could imagine, it’s not easy to identify health care professionals that are willing to go to Guam. So, it’s not meant to be excuses, it’s just meant to show the picture realistically how it is. In your first “State of the VA” address, you spoke of progress being made as well as acknowledged flaws – like those you’ve just mentioned – identified within the VA. There are many programs, initiatives, research, and resources that have been brought to bear. I wondered if you could just highlight one or two. Yeah, the reason why I did the disclosure of where our problems are is because I don’t know how you solve problems if you don’t identify them, tell people where the problems are so you can ask for help, and you can start solving some of those or finding solutions to those problems. I think an example where we’re making really good progress is in a little bit of our research program and a little bit of our clinical program with personalized genomics. The reason why I think this is an important example is because it is bringing VA into the modern era of where health care is going, it’s providing some leadership for the rest of the country, and it provides veterans with 12

state-of-the-art care. So, we have a program called the Million Veterans Program [through which] we’re collecting the genomic material on a million veterans – we’re up to more than 600,000 now – and we can match that with their electronic medical records so we now have genomic material and clinical data. And that can help us in the research side in being able to identify new [discoveries] about how to treat conditions, how to diagnose conditions, maybe how to find new solutions for tough problems that have plagued veterans. But we’re moving that also into the clinical realm by allowing veterans to then get personalized genomic information that can make their treatment that they’re going through personalized or individualized. So, it’s a way that we are focusing on things important to veterans: We are improving the timeliness of information, we are modernizing our system, and we are leading the country because there is no other database of this size or effort of this size anywhere in the country at this point. You mentioned earlier moving to a next-generation electronic health record (EHR), and as I understand it, that will be the same EHR used by the Department of Defense (DOD). How does that benefit the two systems? Well, I think it’s really in some ways almost common sense. We know where every one of our customers is going to be coming from, and that’s the Department of Defense. When you enlist in the military, a record is started on you, your information while you’re in the military is captured, and when you leave the military, you become a veteran. So therefore, why shouldn’t there be a consistency and a continuity of that information if you want to do the best job for your customer? Secondly from a taxpayer/[stewardship] point of view, this just makes sense for the government to have a single system that it can invest in and continue to grow and develop and not have to maintain two separate systems where both the Department of Defense and VA can benefit from their learnings and innovations in clinical informatics. So, I think just in the short period of time since I announced this and these organizations working together, there have been many, many “ah ha” moments where DOD says, “Wow, I didn’t know you were approaching it this way. We can take that and incorporate it into our perspective.” And we know that the DOD has saved us a lot of time and effort because they are already a year-and-a-half into their process. And they’ve been willing to share all that information with us. So, I think this is just good common sense and it’s the right thing to do for veterans.

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Since 2001, certainly, there have been a number of updates, changes, and enhancements to the GI Bill. Could you perhaps describe how the Forever GI Bill – the latest – will improve upon existing benefits for veterans? Sure. The first thing it does is it takes away the 15-year limit on using your education benefits. It essentially allows a veteran to be able to obtain additional education and advancement in their professional career at any point in their life. And I think that, as we’ve seen with so many people who have gotten out of the military, they might have gone into one part of industry, the technology changed, now they’ve become less desired in terms of employability. Now they can go back and they can retrain or educate themselves to be more professionally successful. It also allows veterans to be able to share this educational benefit with their dependents, which is obviously a really important benefit so that they are able to make sure that they can support their family when they want to provide for their family. So, I think those are two major features. And it’s got some other improvements to give people more educational options than they had in the past. The last time we spoke, we discussed you practicing medicine within the VA. I wondered if your responsibilities have increased so much that you’ve had to give that up, or are you still able to do that occasionally? Well, it’s something that is very important to me because it allows me to not only get grounded in why I do this job, but it allows me to get a firsthand understanding of what some of these decisions as secretary may mean. So, I was practicing on Monday this week in Manhattan. I’m making all these decisions about the electronic medical record. And one of my patients I was seeing … travels a lot. So his care was split between a number of VAs and Department of Defense facilities, and I had to find his records to get what medicines he was on, etc. So it showed me – because I had not done this with a patient – I had to go in and out of multiple systems to get his information. I was able to do it, but it was a lengthy process, and it reinforced to me how difficult we’ve made it for some of our clinicians to do their job by not designing a system that was well integrated in the first place. So it clearly is difficult for me at times to get away and to have time to see patients, but it is something that is important to me and I will continue to try to do. What do you feel are the most important or the most difficult challenges facing the VA today and in the near future? I think the overwhelming challenge for us is to regain the trust of the veterans and the American public. When you go through a crisis like we did in

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2014, you can quickly lose that trust, and I think we did. And it’s going to take a long time to rebuild that. I think that we’re on our way to rebuilding that, but I think we have to be in it for the long haul, and you have to be committed to a strategy like transparency and improving service. That’s what my five priorities are about. But ultimately that’s our biggest challenge, because if you don’t have [your customers’] confidence and trust … you really can’t fulfill your mission or succeed at it. I think that the biggest challenge, and I said this yesterday at the hearing, that I face on a very practical level rather than global level is the hiring of employees. It’s a very complex process to hire staff, to get the right staff to want to come, but also then to get them onboard and to keep them, because many people first of all don’t have the correct impression of what it’s like to work at VA, and secondly a lot of people just don’t even know how to approach going about getting a government job and then stick with it through the lengthy process. So, I’m looking for ways to be able to streamline that, because ultimately, organizations like ours are service organizations and that’s all about the people that work in your organization.

■■ “I think the overwhelming challenge for us is to regain the trust of the veterans and the American public.”

What message would you like to deliver to the reader out there? Well, we’ve talked about a lot of the things that we’ve done and that we’re focusing on to make VA better. But I want to make sure that people understand that we are listening to veterans and that we by no means believe that we are where we need to be. We have a lot of work to do. Some of that is going to take very aggressive solutions to get us to where we need to go, but that’s our commitment to make the type of changes to make VA both sustainable and effective for future generations of Americans who serve their country. It comes from a belief that I believe VA is an important part of our national security, that when somebody raises their hand and protects their country that they have to feel confident that the country is going to be there for them when they return, no matter what they face. I think that we have not fulfilled that responsibility always in a way that we should, and that’s what we’re really trying to drive toward. 13

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

WOUND CARE AND HEALING Aiming for zero preventable deaths

n “THE GOLDEN HOUR.” It was a term coined a long time ago – in 1975, when wars were fought much differently, and Dr. R. Adams Cowley, the founder of Baltimore’s Shock Trauma Center, asserted that the first hour after injury would largely determine a critically injured person’s chances for survival. The golden hour has never been a perfect metric, but for military medical professionals, it emphasized the urgency of getting wounded warfighters out of the theater and into trauma care. In 2009, U.S. Secretary of Defense Robert Gates issued a golden hour mandate: Prehospital helicopter transport of critically injured casualties must be done in 60 minutes or less. According to a 2015 report in JAMA Surgery, the secretary’s mandate saved a total of 359 lives. For U.S. service members, the wars in Afghanistan and Iraq dramatically narrowed the window of time available 14

for the critically wounded to survive, as improvised explosive devices (IEDs) became their adversaries’ weapons of choice, and blast injuries far outnumbered gunshot wounds among coalition warfighters. The Washington Post, working from Pentagon casualty notices, has estimated that, through 2014, more than 2,500 service members were killed by IEDs in Afghanistan and Iraq. According to a 2013 article in USA Today, “How the IED Changed the U.S. Military,” the Pentagon has estimated that somewhere between more than half to two-thirds of Americans killed or wounded in combat in Iraq and Afghanistan were victims of “IEDs planted in the ground, in vehicles or buildings, or worn as suicide vests, or loaded into suicide vehicles.” According to Dale Smith, Ph.D., professor of military medicine and history at the Uniformed Services University

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U.S. AIR FORCE PHOTO BY SENIOR AIRMAN SANDRA WELCH

By Craig Collins

U.S. MARINE CORPS PHOTO BY LANCE CPL. JAMES CLARK

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

of the Health Sciences (USU), the hour is no longer golden: “We have increasing data that 90 percent of the KIA [killed in action] are lost in the first 10 minutes after wounding.” The overwhelming majority of those deaths, Smith said, are due to blood loss, or hemorrhage. It would be reasonable to expect much lower survival rates among warfighters who’ve had limbs blown off or suffered multiple injuries – polytrauma – from IEDs. But in December 2013, a trio of military medical experts – Capt. (Dr.) Eric Elster, USU’s chair of surgery; Army Gen. (Dr.) Eric Schoomaker, Ph.D., the recently retired U.S. Army surgeon general; and Dr. Charles Rice, then USU’s president – posted a blog entry on the healthaffairs.org website explaining that actually, the opposite had happened. “At the beginning of operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), the combat injury case-fatality rate was approximately 18 percent,” they wrote. “Over the subsequent decade, it steadily decreased to 5 percent despite an overall increase in injury severity.” This decrease was achieved by improvements throughout the entire spectrum of trauma care, including: • preventive measures such as armoring and training in the doctrine of Tactical Combat Casualty Care (TCCC); • better point-of-injury treatment with improved tourniquets and anticoagulants that helped slow rates of hemorrhaging; • improved “damage control resuscitation” procedures, including a new blood transfusion protocol; • the use of “damage control surgery” to focus on stabilizing a patient for transport to definitive care; and • at the level of definitive care – a hospital, for example – the promotion of long-term healing with negative-pressure (vacuum) dressings and silver dressings. Despite the significant improvements in combat trauma survival rates over the past decade-and-a-half, both military and civilian leaders in trauma care acknowledge room for further improvement. Last year, citing advances in both civilian and military trauma care, the National Academies of Science, Engineering, and Medicine published a report, “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” The report presented “a vision for a national trauma care system driven by the clear and bold aim of zero preventable deaths after injury and minimal trauma-related disability to benefit those the nation sends into harm’s way in combat as well as every American.” SURVIVABLE WOUNDS: THE “TARGET OF OPPORTUNITY”

How will the military know when it’s achieved zero preventable deaths? According to Terry Rauch, Ph.D., acting deputy assistant secretary of defense for health readiness policy and oversight, one of the most influential recent studies of battlefield medicine was conducted by Col. (Dr.)

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■■ ABOVE: A helicopter lands for an emergency medical evacuation

while Marines with Bravo Company, 1st Battalion, 6th Marine Regiment, and Afghan National Army soldiers provide security and prepare to provide covering fire Feb. 13, 2010, on the outskirts of the city of Marjah, Helmand province, Afghanistan. Defense Secretary Robert Gates’ 2009 golden hour mandate – that prehospital helicopter transport of critically injured casualties must be completed in 60 minutes or less – has been credited with saving service members’ lives. OPPOSITE: U.S. Army Spc. Robert Moher, 159th Combat Aviation Brigade crew chief, stands by to deliver blood in Afghanistan, July 2014. A study of prehospital service member deaths published in 2012 showed that a significant number of those losses were associated with hemorrhage.

Brian Eastridge, a retired Army surgeon and former director of the Joint Theater Trauma System (now the Joint Trauma System). Eastridge examined the circumstances of 4,596 American combat deaths between 2001 and 2011, Rauch said, and, “almost 75 percent of them were due to explosions … and it’s most important for us to realize from this analysis that the overwhelming majority of all deaths by traumatic injury, nearly 90 percent, happened before the patient reached a medical treatment facility. That focuses our attention on where we need to improve care: It’s at the point of injury and the time taken to transport them to the MTF [medical treatment facility].” Eastridge’s study of these pre-hospital deaths, published in the Journal of Trauma and Acute Care Surgery in 2012, determined that a little over 75 percent were due to catastrophic, “nonsurvivable” injuries; those patients either died instantly or would have died no matter when they’d arrived at an MTF. “About 25 percent were deemed potentially survivable by Eastridge’s analysis,” Rauch said. “So that is a target of opportunity for us. More than 90 percent of those deaths were associated with hemorrhage. So if you look at where we can make the most difference in focusing our technologies and research investments, it’s in stopping the bleeding at the point of injury.” 15

New Independent Studies Show Exergen Reduces Hospital Costs by 90% Compared to Other Thermometers “Yielded clear-cut cost savings that increased exponentially with increasing duration of use and increasing bed numbers per device.” WATERTOWN, Mass., May 25, 2017 (GLOBE NEWSWIRE via COMTEX) -- Two new studies from Postgraduate Medical Journal indicate that when used throughout a hospital, Exergen TemporalScanners deliver substantial cost savings while providing accuracy and ease of use, as supported by more than 70 peer-reviewed published studies for all ages and clinical settings. The first study, “Cost minimisation analysis of thermometry in two different hospital systems [1] ,” was conducted at University Hospital Centre Zagreb (UHCZ) and University of Michigan Hospitals (UMH), each of which used the Exergen TAT-5000 to evaluate cost savings. Results dramatically favored TAT over tympanic thermometry at UHCZ, where the cost of consumables per measurement would be more than 10 times cheaper for TAT, leading to considerable budget savings within a year of hospital-wide implementation. The UMH study concluded that routine use of Exergen TAT-5000 would lead to cost savings over three years at UMH. The second study, “Minimising the costs of temperature monitoring in hospitals [2] ,” revealed that Exergen TAT-5000 savings exceeded $1.7 million when there were 10 beds per device used for five years. In addition, the study indicated that other forms of thermometry such as oral, axillary and rectal are not favored by hospital staff due to numerous factors including time commitment needed from the healthcare provider, patient discomfort and the potential to wake a sleeping patient. “We appreciate how cost is a critical consideration in hospital purchasing today, and we are committed to providing a product, the Exergen TAT-5000, that delivers significant cost savings,” said Francesco Pompei, Ph.D., CEO of Exergen Corporation. “This has wide implications for maximizing savings, as our thermometer is the single standard of uniform care in hospitals nationwide, giving more healthcare professionals and patients access to its many benefits.” The above, along with other independent studies, confirm suitability among all patient groups, including premature infants, adults and geriatrics, and under all medical conditions. For a complete list of studies visit www.exergen.com/c. [1] Hayes K, Shepard A, Cesarec A, et al. Cost minimisation analysis of thermometry in two different hospital systems. Postgrad Med J Published Online First: 18 January 2017, doi:10.1136/postgradmedj-2016-134630

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[2] Kumana C. Minimising the costs of temperature monitoring in hospitals. Postgrad Med J Published Online First: 1 February 2017 doi:10.1136/postgradmedj-2017-134795

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U.S. MARINE CORPS PHOTO BY LANCE CPL. ANDY MARTINEZ

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The period Eastridge studied was a time of considerable progress in that area, Rauch said. The fielding of tourniquets, which had become widespread after 2007, and the implementation of TCCC undoubtedly saved many lives. Combat deaths due to hemorrhage from limb trauma – bleeding out of an arm or leg – have become increasingly rare. The vast majority of hemorrhage deaths, said Rauch, are caused by injuries to non-compressible anatomical sites, such as the torso or trunk. “More than two-thirds of those with ‘potentially survivable’ wounds were lost due to truncal hemorrhage,” he said. “And then about 20 percent were lost because of junctional hemorrhage – your armpit or your groin.” IED blasts often cause pelvic fractures and high leg injuries, which result in massive blood loss if not immediately treated, but in recent years, Army and Navy medical researchers have field tested junctional tourniquets that, while not quite as simple to use as extremity tourniquets, can be deployed in about a minute and stop bleeding with inflatable bladders that compress arteries against adjacent bone. The SAM® Junctional Tourniquet, one such device, was cleared by the Food and Drug Administration (FDA) in 2013 for inguinal (groin) use, and was later cleared for axillary (armpit) use and pelvic binding. While bleeding from the trunk poses a greater risk of death – its major blood vessels, including the aorta, cannot be compressed from the outside, as a tourniquet does – recent innovations have solved this problem by supplying compression from the inside. About a decade ago, Drs. Todd Rasmussen

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■■ A Marine with 3rd Reconnaissance Battalion, 3rd Marine

Division, III Marine Expeditionary Force, applies a tourniquet to a simulated casualty during the Tactical Combat Casualty Care (TCCC) course at the Tactical Medical Simulation Center, Camp Hansen, Okinawa, Japan, July 13, 2017. The fielding of tourniquets and the implementation of TCCC have increased survivability on the battlefield.

and Jonathan Eliason, Air Force surgeons in Iraq, began looking at ways to adapt a method used in hospitals to stop aortic bleeding during surgery: the resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter. Inserted via the femoral artery, it could be deposited at or above the site of an aortic wound and inflated to block blood flow – but the surgical version was cumbersome and required X-ray guidance. Rasmussen and Eliason refined it into a smaller, stripped-down version, the ER-REBOA™ Catheter, that could be used by forward surgical teams in small field hospitals to stop bleeding from the aorta, the primary conduit from the heart to most of the body. Deployment of a REBOA catheter is a potentially dangerous procedure – aortic blood flow can only be cut off for about 30-40 minutes before causing irreversible damage to the tissues of the legs and internal organs – and requires training. But it offers precious time to get a wounded patient to an MTF, where a surgeon can pack the wound and stop bleeding before deflating the catheter. Rasmussen and Eliason fielded their first version of the ER-REBOA Catheter in 2009, and the idea was picked up and 17

PHOTO BY BRAD GILPIN

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■■ The XSTAT 30 (shown close up in the inset photo) is demonstrated in a battlefield setting. The XSTAT hemostatic dressing can be used to stop bleeding from wounds in normally non-compressible junctional sites.

“bridge to surgery.” The culmination of a public/private project launched in 2010 and led by the Defense Advanced Research Projects Agency, the “rescue foam,” as Rauch calls it, “is a selfexpanding biocompatible material that you can administer at the point of injury to stop massive blood loss in casualties suffering from abdominal trauma. You inject the material, and it fills and conforms to the abdominal cavity and controls the bleeding.” The foam can be left inside the patient for up the 3 hours, buying valuable time for a patient to be transported to a surgical facility for definitive care. THE MICROENVIRONMENT: THE SURGICAL CRITICAL CARE INITIATIVE

Efforts to improve combat wound care and healing, as Elster pointed out, have been implemented at every point along the continuum of care, and a recent initiative involving multiple partners in the military medical community – including USU, Walter Reed National Military Medical Center, Duke University, Emory University, and DecisionQ, a predictive

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REVMEDX. INC. PHOTO

developed by the startup Prytime Medical. Cleared for distribution by the FDA in 2015, the catheter has saved lives in both military and civilian settings. Since 2015, an innovative hemostatic dressing, the XSTAT®, has been successfully used by far-forward military medical personnel to stop bleeding from wounds in normally noncompressible junctional sites. The XSTAT, developed by the Oregon-based RevMedx, Inc., is basically a large-bore syringe filled with tiny sponges impregnated with coagulant. Once injected into a wound, the sponges expand to fill the wound cavity and apply pressure, providing a physical barrier to blood flow for up to 4 hours. The FDA cleared the XSTAT for use in both military and civilian trauma cases in May 2016. The XSTAT’s application, however, is mostly limited to junctional wounds; it’s not indicated for wounds to the trunk – the abdomen and thorax. Wounds here, as Rauch pointed out, account for the majority of preventable combat deaths due to blood loss, and until recently, there was no good choice for preventing blood loss from truncal wounds. In early 2017, the Army Medical Materiel Agency took its first steps toward a clinical trial to evaluate the safety and effectiveness of what Rauch calls an “intracavity noncompressible hemorrhage control agent”: an expandable foam, remarkably similar to the agent used to seal and fill household gaps and cracks, that can be injected into a wound to provide a

U.S. AIR FORCE PHOTO BY TECH. SGT. JOSEPH SWAFFORD

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

analytics company – is aimed at optimizing recovery from traumatic wounds in definitive care settings. When a person suffers a traumatic wound, Elster explained, the timing of its final closure is a critical decision. “We call it delayed primary closure – a skin graft may be placed over the wound, or some type of complex flap reconstruction is performed.” The timing of that final closure is determined based on when the surgeon estimates the risk of infection is lowest. “That decision is made correctly about 85 percent of the time,” Elster said, but that means surgeons get it wrong 15 percent of the time. “And there’s a price to that: more time in the hospital, more risk of complications, a longer period of time before you rehabilitate and get where you need to go – and a dollar cost, as well. In fact, when you get that single decision wrong, it creates about $60,000 in hospital-associated costs.” The Surgical Critical Care Initiative (SC2i) is a precision medicine initiative, designed to create decision tools for surgeons that combine a patient’s clinical information with data about inflammatory biomarkers – both local, from the wound exudate, and systemic – and produce a target window for optimal wound closure. “Systemic inflammation and the local response can change the microbial flora,” said Elster, “so you have an infection, or an impairment of the ability of those proteases involved in remodeling to effectively begin the process of wound healing.” The idea, Elster said, is to focus wound care around a patient’s individual biology, rather than to blindly follow traditional protocols. “We’re building these tools not to replace but to enhance the decision-making of

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■■ U.S. Air Force Maj. Stephen Varga, 455th Expeditionary Medical

Group, performs surgery on a soldier who had sustained a gunshot at the Craig Joint Theater Hospital, Bagram Air Field, Afghanistan, Sept. 26, 2015. The military is working toward a unified medical trauma system that fosters a patient continuum of care from the battlefield through to hospitals and further sites of treatment.

clinicians.” About 1,600 patients around the country have been enrolled in evaluations of SC2i’s decision tools. Many U.S. service members remain deployed overseas, and while the number of casualties has decreased significantly in recent years, Elster said the military medical community isn’t taking anything for granted: Efforts are underway in the military medical community to maintain and even accelerate the gains that have been made in lowering the rate of preventable combat deaths. The Joint Trauma System continues to refine and codify clinical guidance for the continuum of patient care – working in collaboration with civilian counterparts to achieve the vision of a national trauma care system that approaches zero preventable deaths – while implementing training and education programs to maintain currency and competency among expeditionary surgical teams. “We’ve gotten better, even as the enemy has gotten more resourceful in their ability to cause injury,” said Elster. “But we need to maintain and build proficiency – to not only keep that combat fatality rate at 6 percent, but to drive it down even further.” 19

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THE NATIONAL CENTER FOR PTSD At the forefront of trauma research and education

n WHAT WE NOW KNOW AS post-traumatic stress disorder (PTSD) – a mental health problem some people develop after experiencing or witnessing a life-threatening event – is likely as old as the human brain, but for the Department of Veterans Affairs (VA), the effort to establish a national center for supporting and counseling military veterans gained momentum during and after the Vietnam war, as the growing mental health needs of returning American veterans became clearer. At the time, there was no professional consensus about where PTSD came from. Early concepts of trauma-induced mental health problems – “railway spine” for victims of 19th century railway accidents, or “shell shock” for World War I combatants – focused on physical injury to the nervous system as the cause. Among others who believed a stress reaction to trauma was caused by psychological rather than biological factors, some maintained the reaction was due to inherent mental vulnerability. In 1980, when the American Psychological Association (APA) named PTSD as a disorder and added it to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM) classification scheme, its diagnosis made two important distinctions: First, it stipulated that PTSD’s “etiological agent,” 20

or cause, was external – a traumatic event outside the range of usual human experience – rather than an inherent “neurosis” or weakness. Second, it made clear that PTSD was a psychological disorder that may or may not be linked to physical injury – though the two are not mutually exclusive. VA clinicians had been discussing ways to help returning Vietnam veterans cope with trauma for many years, and after the APA’s diagnosis was formalized, research into the neurobiological response to trauma accelerated. In 1984, Congress directed the VA to form a National Center for PTSD “to carry out and promote the training of health-care and related personnel in, and research into, the causes and diagnosis of PTSD and the treatment of veterans for PTSD.” When the center was established in 1989, one of its earliest contributions was to simply validate, by its very existence, the APA’s diagnosis – which, at the time, wasn’t universally accepted. Paula Schnurr, Ph.D., the Dartmouth College psychiatry professor who became executive director for the National Center for PTSD in 2015, was involved in the center’s formative stages. “At our very first meeting,” she said, “we asked ourselves: What was the single most important thing we needed to do to move the field forward? And we came up with the idea of

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By Craig Collins

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■■ RIGHT: The White River Junction VA

VA PHOTO

Medical Center houses the administrative arm of the National Center for PTSD as well its Rural Mental Health Initiative. OPPOSITE: The National Center for PTSD was established in part to research “the causes and diagnosis of PTSD and the treatment of veterans for PTSD.” One such example of the center’s research was a study focusing on treating PTSD in women veterans that showed prolonged exposure therapy was effective.

developing a clinical diagnostic interview that would promote an accurate diagnosis, and also provide an accurate measure of severity, so we could use it for gauging treatment response. We believed that by having a standardized clinical tool that was specialized to assess PTSD, we could immediately move research and clinical care.” In 1989, few effective treatments for PTSD had been identified and many clinicians were focused on coping with the disorder, rather than overcoming it. The tool developed by the center’s experts, the Clinician-administered PTSD Scale (CAPS), helped fill an important gap in standardizing and enhancing the assessment of PTSD. It’s difficult to overstate how influential the National Center for PTSD, which has grown into one of the world’s leading establishments for research and education on the disorder, has changed the way people – clinicians, researchers, veterans, and the general public – think about PTSD. The center has shaped our basic understanding of the disorder, bolstering the APA’s diagnosis by publishing and disseminating some of the first evidence of PTSD-related biomarkers. “At the time we opened, in 1989, there had been some published reports about biological changes associated with PTSD,” Schnurr said, “and some of the early focus was on stress hormones and neurotransmitters in the brain. But the National Center published the first paper showing anatomical changes in brains that were associated with PTSD. A number of people since, not only the National Center but a number of other people, have been contributing to the literature. We think this publication was critical in expanding the knowledge and opening new doors into research on PTSD.” Today, a wide range of available treatment options, both pharmacological and psychotherapeutic, can be tailored to the needs of individuals and help achieve meaningful improvements in their daily lives. Research has established that these treatments work – and the center’s multiple education and outreach programs are ensuring that a growing number of people know about them.

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“From its very beginning,” said Schnurr, “one of the center’s strengths has been its integrated focus on research and education. We don’t have a separate research budget or a separate education budget. We have some people who are primarily researchers, or primarily educators, but from our very beginning, we tried to integrate people in those communities to enhance research and education and make sure those efforts work hand in hand.” COMBINING RESOURCES AND EXPERTISE

The National Center for PTSD, while administered by its Executive Division in White River Junction, Vermont, isn’t a “center” in the strictest sense; the reason it was so effective so quickly is that it wasn’t launched from scratch – it was built around existing centers of expertise across the country, which function today as operational divisions. The Behavioral Science and Women’s Health Sciences divisions are in Boston; the Clinical Neuroscience and Evaluation divisions are in West Haven, Connecticut; and the Dissemination and Training Division is in Palo Alto, California. The Pacific Islands Division, in Honolulu, emphasizes cross-cultural factors in the expression, assessment, and treatment of PTSD among ethnic minorities. The combined expertise of people in these divisions, along with partners in the Department of Defense (DOD) and academia, have brought the National Center to the forefront of PTSD and trauma research. As it sets international standards for promoting better assessment and treatment of PTSD, and for advancing the scientific understanding of it, the National Center continues to look for ways to get help to as many veterans and families as possible. It does this in several ways: • Leveraging resources for research. When Schnurr and her colleagues began their careers, most research was done in laboratories and funded by grants. A good amount of any 21

■■ The capabilities and expertise of the National Center for PTSD are

spread among seven divisions across the country.

investigator’s time was spent in the pursuit of these grants, and a good amount of research was done in relative isolation, or with a small group of co-investigators. The National Center’s founders wanted a different model: paying a salary to a core group of investigators, and allowing them time to pursue collaborative relationships with other experts in the field. “In order to help our researchers to maximize their productivity,” said Schnurr, “and to enable them to work not only in the areas that might be most fundable, but in the areas they believed were most important, we chose to use money to pay salaries of researchers.” Freeing investigators from the money chase, she said, gave them more room to collaborate – and to participate in educational and outreach initiatives. “Team science is the way we do research,” she said. “We want relevant people to collaborate across the center. And by providing hard money and protected time, we can support that.” Many National Center researchers still pursue grants, and bring these opportunities to colleagues across the enterprise. • Facilitating access to PTSD treatment and services. The National Center has several strategies for connecting veterans with mental health professionals and services. Its PTSD Consultation Program was launched in 2011 to offer advice, education, training, information, referrals, and other resources to VA providers – and the program was recently extended to non-VA community providers treating veterans. “Any provider helping a veteran anywhere in the U.S. can call us,” said Schnurr. “That’s important because many veterans find it more convenient to seek care outside of VA, and many of these providers don’t have access to the kind of national 22

resources and training, the specialized clinical program, that VA provides in treating PTSD. Our Consultation Program helps veterans access the best evidence-based care.” The National Center also uses information technology to link patients and service providers, either via the internet or through videoconferencing, and its researchers continue to find that these modes of therapeutic interaction are both effective for PTSD and acceptable to patients. • Improving the quality of care. About a decade ago, as the VA added a significant number of mental health providers to serve Afghanistan and Iraq veterans, the National Center established a mentoring program to provide advice and support to all directors of specialized PTSD clinical programs. For those who direct outpatient services, Schnurr said, time is always a complicating factor, and implementing best practices and management skills is a challenge. “Some of the evidence-based treatments have additional time requirements that may be hard to balance against the need to ensure timely access,” she said. “It may require some rearranging of the program structure – which clinicians are doing which treatments, and so on. We provide support for these leaders, both one on one and in a national forum, to help them enhance the quality of the care they’re delivering in their specialized program.” For rural veterans suffering from PTSD, the National Center began a pilot project, the Rural Mental Health Outreach Initiative, in 2014. Administered by the White River Junction VA Medical Center and involving community-based outpatient clinics, the initiative involves periodic visits from a clinical mental health pharmacist who delivers customized education related to consultation, prescribing practices, and overcoming barriers to care. The long-term goal of the initiative is to implement similar programs in other rural VA medical centers around the country.

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NATIONAL CENTER FOR PTSD-U.S. DEPARTMENT OF VETERANS AFFAIRS FACEBOOK PAGE

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VA IMAGES

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• Maximizing outreach through information dissemination, training, and education. “When we started,” Schnurr said, “we literally trained people face to face. We put training material in the mail.” The National Center launched its primary outreach tool, its website, in 1995 – early, for a government portal; it’s only a year younger than the White House’s. The National Center’s web presence has evolved into a major conduit of interaction and exchange, its primary distribution vehicle for research and educational materials. This outreach is extended to VA and community providers, researchers, and veterans and their families, and information technology is an increasingly significant means of connecting people to the help they need. In 2011, the National Center and DOD jointly developed the first publicly available VA mobile app, “PTSD Coach,” which won the 2012 Innovation Award for Telemedicine Advancement by the American Telemedicine Association. AboutFace, an online video gallery of veterans and their family members talking about living with PTSD and how treatment has helped them, has proven a valuable tool for correcting the misconceptions many people have about PTSD and its treatment. “We’re hoping that someone sees themselves, or a family member, in an AboutFace segment, and gets motivated to get themselves or a family member into care,” said Schnurr. • Converting research into practice. The National Center was a key contributor to the development of the VA/ DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Reaction, and continues to create national training programs in modes of treatment such as Cognitive Processing Therapy or Prolonged Exposure (PE) therapy. Prolonged exposure therapy, a type of cognitive behavioral therapy that teaches patients to gradually re-approach longburied trauma-related memories and feelings, is an example of a National Center research initiative whose findings were adopted nationwide in the treatment of PTSD. Until a few

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■■ Screen captures from “PTSD Coach,” the VA mobile app. The

award-winning app is one way the National Center is working to educate and disseminate information about PTSD.

years ago, the body of literature on PE therapy was based mostly on female subjects who had been sexually assaulted. “It looked promising,” Schnurr said, “but we had no evidence about its translation to a military veteran.” Schnurr and Matthew Friedman, M.D., Ph.D., National Center co-founder and its executive director from 1989 to 2014, teamed with Col. Charles Engel, M.D., M.P.H., of the Army Medical Corps to evaluate the effectiveness of PE therapy in treating PTSD of women veterans and activeduty service members at VA facilities and Walter Reed Army Medical Center, an evaluation conducted from 2002 through 2005. The study – the first to focus on treating PTSD in women veterans – showed that PE therapy was effective. After it was published in the Journal of the American Medical Association, it received much attention, “and we went from doing the research to training providers nationwide in the therapy,” Schnurr said. “It’s one of the most effective treatments for PTSD, and it’s recommended as a first-line treatment in all of the practice guidelines for PTSD, not only in VA but around the world.” Without the ability to embrace a nationwide pool of research subjects through VA facilities, Schnurr said, it wouldn’t have been possible to achieve a large-scale study of the effectiveness of prolonged exposure therapy for PTSD. “I’m so glad to work in the VA,” she said. “It couldn’t have happened anywhere else. We have the infrastructure where we can fund and conduct the research, deliver the treatment, and push what we’ve learned out to everyone at the national level.” 23

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FORCE HEALTH PROTECTION Battlefield medicine evolves beyond the battlefield.

n IN 2000, THE DEPARTMENT OF DEFENSE (DOD) released its grand strategy for the 21st century, which it called “Joint Vision 2020.” The document famously called for the U.S. military to achieve “full spectrum dominance” over all land, sea, air, space, electromagnetic, and information systems, with enough overwhelming power to fight and win global wars against any adversary. The new strategy contained a medical annex that became known as “Force Health Protection,” which by itself doesn’t sound very radical: In order to achieve full-spectrum dominance, obviously, the military needs people who are healthy enough to dominate, and who stay healthy enough to keep

dominating. It’s a phrase that echoes the motto on the scroll of the Army Medical Department regimental flag: “To Conserve Fighting Strength.” Gen. George Washington was perhaps the first American commander to actively conserve fighting strength, when he quarantined his Continental Army soldiers to protect them from a rampant smallpox epidemic at the outset of the Revolutionary War – and later, in 1777, when he instituted a system of inoculating soldiers against the smallpox virus. Since World War II, the Navy Medical Department has provided a similar description of its wartime mission: “To keep as many men at as many guns as many days as possible.”

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ARMY PHOTO/JOHN PENNELL

By Craig Collins

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To understand what’s new about the phrase “force health protection,” it helps to realize it isn’t meant to describe a new idea: It describes a new way of thinking about an old idea.

U.S. AIR FORCE PHOTO BY MAJ. BRANDON LINGLE

TOWARD A NEW MILITARY MEDICAL STRATEGY

The evolution of force health protection as a strategy – which is by no means complete today – has been gradual enough that it’s difficult to point to a single cause. Dale Smith, Ph.D., a professor of military medicine and history at the Uniformed Services University of the Health Sciences (USU), points to two trends that began during and after the Vietnam War: First, the idea of “fighting strength” began to extend beyond the notion of physical combat. Army Maj. Frederick M. Franks, suffering a grievous wound to his left leg during heavy fighting in Cambodia in 1970, eventually had the leg amputated below the knee. At the time, it was customary for military medicine to focus on conventional combat medicine and casualty care, and amputees were almost automatically considered veterans – their military service had effectively come to an end. Caring for them, then, was no longer a component of military medicine. “It’s not a military problem anymore,” Smith said, “if you’re not going to come back to duty.” But Franks fought to remain in a combat unit after losing his leg, arguing that he could still command, even if he couldn’t fight. The Army agreed, and other officers followed Franks’ lead. Smith said: “It wasn’t until Vietnam that officers like Franks really said: ‘Wait a minute here. I’m a division-level field-grade officer. It’s not likely that I’m going to engage in hand-to-hand combat. But I can lead my battalion and serve on a staff with a fake limb.’” Franks served for another two decades with distinction, and during his career he earned several valor awards, including the Silver Star, Distinguished Flying Cross, the Bronze Star, the Air Medal, and two Purple Hearts. In the Gulf War of 1990-1991, he commanded the coalition forces’ VII Corps, which decimated Iraqi forces, including a number of Iraqi Republican Guard units. He retired in 1994 at the rank of general.

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■■ OPPOSITE: Soldiers from C Troop, 5th Squadron, 1st Cavalry Regiment, 1st Stryker

Brigade Combat Team, 25th Infantry Division, take part in Operation Denali Conquest, a 26.2-mile foot march along the park road in Denali National Park, Alaska, July 26, 2017. The Department of Defense’s force health protection strategy aims to ensure that troops maintain good health on and off the battlefield and through the course of their military careers. ABOVE: U.S. Air Force Senior Airman Bryant Wilson, U.S. Army Sgt. Ted Werre, and U.S. Air Force Maj. William Leasure rush a patient into the Craig Joint Theater Hospital during a mass casualty response at Bagram Air Field, Afghanistan, on Aug. 5, 2014. In the 21st century – after the attacks of Sept. 11 – the mission of military medicine began to expand to include stability operations.

After the military draft was abolished in 1973, Smith said, the all-volunteer force began to emphasize professionalism among its service members. Over the next two decades, the U.S. military became increasingly composed of career service members, many with families and many who would grow old in service to their country. As ideas about “fitness for duty” began to shift, so too did traditional ideas about medical readiness planning. At the same time, the mission of military medicine began to expand in the 21st century. The 9/11 terrorists were able to plan and coordinate their attack relatively undisturbed in Afghanistan, one of the many failed states to emerge after the collapse of the bipolar world order. It became clear to U.S. military leaders that the doctrine of “full-spectrum dominance” must necessarily include operations that would help to stabilize such states before their weaknesses posed a threat to national security. U.S. military personnel have often deployed to provide stability and support operations (SASO), mostly for humanitarian reasons, but the clear security threats posed by failed states have made SASO not only a moral but a strategic imperative for the DOD. The Military Health System adopted SASO as a stated mission in 2002, and the National Defense Strategy has since elevated SASO to be a mission on par with the military’s traditional combat missions, offense and defense. It’s a historic change in how the U.S. military sees itself: Its mission is not only to win battles, but to create space for negotiation by providing a controlled, nonviolent environment and by providing 25

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■■ Capt. Shawn Palmer, a biochemist with the 1st Area Medical Laboratory (AML), based out of Aberdeen Proving Ground, Maryland, breaks

U.S. ARMY PHOTO BY STAFF SGT. TERRANCE D. RHODES, JOINT FORCES COMMAND – UNITED ASSISTANCE PUBLIC AFFAIRS

down a biological safety level three glove box at the 1st AML’s Ebola testing lab in Zwedru, Liberia, Feb. 9, 2015. The glove box is built to provide maximum personnel and environmental protection from high-risk biological agents. Soldiers of the 1st AML used this equipment to test blood samples of suspected Ebola patients during Operation United Assistance, a Department of Defense operation in Liberia to provide logistics, training, and engineering support to U.S. Agency for International Development-led efforts to contain the Ebola virus outbreak in western Africa.

aid to civilians. DOD participation in the global response to the 2014 Ebola outbreak in West Africa is a noteworthy example of such an operation: In addition to the commandcontrol and logistical support provided by soldiers, sailors, and Marines, Operation United Assistance featured crucial assistance from the military’s – and the world’s – leading infectious disease experts. Researchers and physicians from the Army, Navy, and Air Force diagnosed cases, prevented the spread of the virus, and researched and field-tested Ebola treatments and vaccines. Such deployments, obviously, elevate certain health risks for service members. “You’re much more likely to be exposed to disease if you go in to fight Ebola,” Smith said, “than if you go in to fight insurgents.” The strategic evolution toward force health protection – in particular, a stronger emphasis on health surveillance – gained considerable momentum after the Gulf War, where medical personnel from all branches performed well, both in theater and in European hospitals to which some wounded were evacuated.

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But what happened after the war caught the military medical community off guard: A significant number of both veterans and civilian workers returning from the Persian Gulf experienced a chronic multi-symptom disorder that became known as Gulf War Syndrome. Studies revealed much higher rates of chronic multi-symptom illness among Gulf War veterans than among the general population: About 250,000 of the 700,000 U.S. personnel deployed to the region suffered from persistent, unexplained symptoms including fatigue, muscle and joint pain, rashes, and cognitive problems. Investigations by the military and the Department of Veterans Affairs (VA) into the nature and causes of these illnesses were severely hindered by a lack of health and deployment data. It wasn’t until six years after the war’s end, in the National Defense Authorization Act of 1998, that Congress directed the DOD to establish a system for assessing the medical condition of service members before and after deployment. A longitudinal health record (LHR) was implemented to provide and track data before, during, and after deployment. The object in forming this “cradle-to-grave” data set 27

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ Maj. Jamie Kurzdorfer, School of Aerospace Medicine Force Health Protection branch chief (left), annotates the time when Airman 1st Class

was to enable military medical professionals both to foresee and prevent any service-related health issues, and to connect emerging issues with existing information regarding deployment and exposures. The Pentagon established a deployment health quality assurance program in 2004, launching the development of readiness standards and metrics, as well as a joint-service automated theater-wide health data surveillance and reporting system. Around the time this program was established, the DOD released its revised force health protection vision document, which described how the 9/11 attacks and the ensuing global war on terrorism had further transformed American military service. Military deployments, the authors said in their introduction, had increased in number and frequency, and the Pentagon was satisfying those requirements with a smaller force, comprising both active and Reserve components – with 28

an increased proportion of reserves. “In short,” the authors wrote, “U.S. forces are more active, mobile, and dispersed than they were in the past, and they are also more likely to work in joint operations and partnerships with others. The well-being and fitness of U.S. forces for duty is more important and more complicated than ever.” WHAT FORCE HEALTH PROTECTION LOOKS LIKE TODAY

This accumulation of post-Vietnam considerations broadened military medicine’s focus in two ways: It extended the focus in terms of time, to consider health both before and after deployment, and in terms of the nature of one’s service, beyond a strict focus on combat arms. The DOD directive issued in 2004 described force health protection measures as “encompassing the full spectrum of missions, responsibilities,

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U.S. AIR FORCE PHOTO/SENIOR AIRMAN JAMES HENSLEY

Eric Ruiz-Garcia, 63rd Aircraft Maintenance Unit crew chief, gives an air sample at Luke Air Force Base, Arizona, Aug. 22, 2017. Ruiz-Garcia also wore air sampling devices and thermal stress monitors during the launch and recovery of an F-35A Lightning II. The purpose of the test is to collect real-time data of the air quality and the core temperatures of the maintainers during a launch. Today, part of the force health protection doctrine includes such health surveillance measures to promote and sustain health and wellness and to prevent acute and chronic illnesses and injuries.

U.S. NAVY PHOTO BY MASS COMMUNICATION 2ND CLASS MICHAEL J. LIEBERKNECHT

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

and actions of the DOD Components in establishing, sustaining, restoring, and improving the health of their forces.” Said Smith: “These various components related to recruitment, preventive medicine, and rehabilitation all began to be brought together after the First Gulf War, into this new overall rubric of force health protection. There’s nothing new in it, except it’s now a single doctrinal node.” Today, this doctrine balances the Military Health System’s primary mandates: to promote and sustain health and wellness throughout each person’s military service; to prevent acute and chronic illnesses and injuries during training and deployment; and to rapidly stabilize, treat, and evacuate casualties. “Force health protection,” said Terry Rauch, Ph.D., acting deputy assistant secretary of Defense for Health Readiness Policy and Oversight, “is basically all measures taken by commanders, supervisors, individual service members, and our medical enterprise to promote, protect, improve, and restore the mental and physical wellbeing of service members. And that spans all military activities and operations. These force health protection measures enable the fielding of a healthy and fit force, help us prevent injuries and illnesses, and protect the force from health hazards generated by military operations. They also provide rehab care to wounded, ill, and injured.” That description covers a lot – it’s meant to – but it doesn’t explain how military medicine might look different in the force health protection era. The key difference, Rauch said, is that, “all of our components implement these programs and processes of force health protection” – if you’re a military neurosurgeon, for example, you will learn about things such as dietary standards, dental health, public health research, tobacco use, and stress management techniques. If you’re a deployed service member, you may, in the near future, be outfitted with a wearable array of sensors that will monitor and analyze the interplay between what’s going on inside you – your vital signs, for example – and outside you in the environment. Several such systems, researched for the last several years among the separate branches, have evolved into a single joint development program. “Our goal in this,” said Rauch, “is to have a suite of sensors, worn by the individual service member, that would capture data on all exposures and experiences at any point in time, analyze it, and send that analysis to inform decision-makers of anything potentially harmful to that service member.” Such a system will be a natural evolution of the cradle-to-grave data set, to include real-time updates on the hazards confronted by deployed service members. Preventive military medicine dates to Washington and the Siege of Boston, but it wasn’t until 2010, when the U.S. Army Public Health Command was established, that the Army elevated it to the level of a command. Force health protection requires all military doctors to learn some preventive medicine – a stipulation that yielded immediate results in 2003, when Joint Task Force Liberia, with an operational

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■■ A Tactical Combat Casualty Care (TCCC) instructor, right,

gives advice to Lt. Gabriel Spence during a field exercise as part of a TCCC Instructor Course at Naval Hospital Pensacola (NHP). The most recent National Defense Authorization Act calls for standardized TCCC training for both combatants and forward medical teams.

component of 3,000 U.S. Marines, deployed to help stabilize the West Africa nation in the midst of a civil war that had created a refugee crisis. “In Liberia,” said Smith, “it was a surgeon who recognized that some of those Marines had malaria. Why? Because he had extra preventive medicine training that a surgeon wouldn’t normally get, because the military was refocusing on this new force health protection strategy.” Because force health protection is envisioned as lifecycle health support, the same holds true on the battlefield, as the military’s Joint Trauma System has promoted the idea that knowledge of the military’s evidence-based Tactical Combat Casualty Care (TCCC) guidelines should go beyond forward medical teams to reach the combatants themselves. The most recent version of the National Defense Authorization Act calls for standardized TCCC training for combatants as well as forward medical teams. “If you’re going to return wounded people to duty,” Smith said, “you’ve got to keep them alive. And often the medic can’t keep them alive, because the medic is not there. So we’ve got to teach people enough about it to keep their buddies alive until the medic can reach them.” If standardized TCCC becomes DOD policy, Smith said, “then at all the new recruit stations … people are going to begin to learn some level of tactical combat casualty care. That will be a new evolution in force health protection. So in both prevention and in returning people to duty, force health protection continues to be dynamic and evolving.”

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

INTERVIEW

SEN. JON TESTER Ranking Member of the Senate Committee on Veterans’ Affairs By Rhonda Carpenter n SEN. JON TESTER is a third-generation Montana farmer, a proud grandfather, and a former schoolteacher who has deep roots in defending veterans in Montana and across America. Tester and his wife, Sharla, still farm the same land near Big Sandy that was homesteaded by his grandparents in 1912. As a teenager, Tester played Taps at many funeral services for World War II veterans. These ceremonies left a deep impression on him – an impression that motivates his work today as the ranking member of the Senate Committee on Veterans’ Affairs. Tester’s first bill to pass in the Senate successfully raised the veterans’ mileage reimbursement rate for the first time in decades. Since then, he has worked with Republicans, Democrats, secretaries, and presidents from both political parties to pass meaningful legislation that upholds the nation’s commitment to veterans. Just this year, Tester has been working closely with Department of Veterans Affairs Secretary David J. Shulkin, M.D., and President Donald Trump to pass five major veterans bills that reform the Choice Program, expand GI Bill benefits to more veterans, and fix the outdated appeals process. Tester continues his work today by holding public listening sessions with veterans so he can take their ideas with him back to the Senate and make meaningful change on the ground in Montana.

■■ Sen. Jon Tester, D-Mont.

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JON TESTER FLICKR SITE

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Veterans Affairs & Military Medicine Outlook: The Veterans Choice Program Improvement Act – an extension of the Veterans Choice Program that was set to expire – was signed into law April 19. What are some of the changes that were included? How will these changes affect veteran patients and their caregivers? Sen. Jon Tester: The Choice Program was designed with the best intentions – to speed up access to care for veterans. For many veterans in Montana and across the nation, it has done the opposite. So I worked closely with Republicans and Democrats to pass this legislation that will begin to fix the Choice Program. Our law will make sure that veterans aren’t bearing the brunt of costs and providers are getting paid in a more timely manner for caring for veterans. It makes the VA [Department of Veterans Affairs] the primary payer under the Choice Program, which cuts red tape and reduces out-of-pocket expenses for veterans. Your home state, a rural state, is reported to have one of the nation’s largest veteran populations per capita. How does the

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Improvement Act help veterans in rural communities? Montana veterans have never shied away from serving their nation when they [are needed] most. And after they serve, many of them want to go back to the rural communities where they grew up. Rural veterans face unique challenges to accessing VA health care. Rural veterans are more likely to qualify for the Choice Program because of their distance to VA facilities, so this law will help those that rely on getting care closer to home by cutting red tape and out-of-pocket costs. Senate Bill 1963, better known as the Caregivers and Veterans Omnibus Health Services Act, was signed into law in May 2010. Veterans eligible for the Program of Comprehensive Assistance for Family Caregivers are those who were injured on or after 9/11. But veterans from the Vietnam and Gulf wars aren’t covered. What are your thoughts on this? Caregivers sacrifice their own physical, emotional, and financial well-being to care for veterans. And veterans who have a dedicated caregiver can recover faster and can

■■ Sen. Jon Tester at a

Veterans Stand Down event in Great Falls, Montana, on Oct. 3, 2014. Stand Down events connect veterans with health care and social services.

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stay in the comfort of their own home. Every veteran who is wounded in the line of duty should be eligible for these support services, which provide their caregivers with training, health care, and other services. They often make the difference between a veteran staying at home and living in a nursing home, not to mention that caregiver benefits are cheaper than nursing home care, which is a good stewardship of taxpayer dollars. I reintroduced legislation that will expand these caregiver support services to veterans of all eras. I am hopeful that momentum is building around this effort and that we can get something done for these folks that can’t receive these benefits. There have been complaints that rules for the Program of Comprehensive Assistance for Family Caregivers seem arbitrary and people were being dropped. The VA has stopped dropping caregivers. Could you talk about this? It’s unacceptable that any veteran and their caregiver would get dropped from this program and without any notice. I immediately

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called on VA Secretary David Shulkin to investigate why folks were being dropped. And while we prevented any other veterans getting dropped, there were still troubling discrepancies between state programs and questions about the future of the program. The VA conducted a full-scale investigation and I’m hopeful that they will keep my recommendations to fully maintain the program in mind. What are some of the differences between the Caregivers and Veterans Omnibus Health Services Act and the Veterans Choice Program Improvement Act? The fundamental difference is that the Caregivers and Veterans Omnibus Health Services Act focused on building a program for seriously disabled veterans. The Veterans Choice Program Improvement Act is a law that helped prevent veterans who rely on the Choice Program from being cut off from their care. The Choice Program was slated to run out of funds sooner than expected, and we passed bipartisan legislation to make sure veterans can continue to access health

■■ President Donald Trump

signs the Department of Veterans Affairs Accountability and Whistleblower Protection Act in the East Room of the White House on June 23, 2017. Sen. Jon Tester helped to craft the legislation.

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care and to make the program work better for them. That allows us to keep veterans seeing their doctors while we craft the future of community care – which should be an integrated network of VA and community care providers, with the VA serving as the coordinator and primary provider of care and any gaps in that care filled by the private sector. You introduced S.833, the Servicemembers and Veterans Empowerment and Support Act. In what ways would this legislation help survivors of military sexual trauma? The fact that anyone in uniform has to deal with sexual assault or harassment while serving our country is unacceptable. We owe it to every woman and man affected by these awful acts to ensure they have access to the best possible care and the benefits they need. So my bipartisan bill will help make sure that the VA is providing the appropriate benefits and care to survivors of military sexual trauma. And since we live in the 21st century, our bill makes sure that veterans and service members who experience online sexual harassment are getting the appropriate care they need. Another piece of legislation you helped craft is the Department of Veterans Affairs Accountability and Whistleblower Protection Act, which was signed into law on June 23. It will give Shulkin more latitude to discipline bad employees. Do you think this law goes far enough to hold accountable poorly performing employees throughout the VA health system? If not, what further steps would you support to ensure veteran patients are treated in a timely manner and with respect and dignity? Most VA employees are hardworking men and women who provide excellent services to veterans. But when there’s a bad apple at the VA, it spoils the whole bunch. The VA needs the authority to get rid of those employees, and we gave VA that authority without sacrificing employees’ due process rights. But true accountability is about more than just discipline. We also need to improve training for managers and incentivize them to address problem behavior before a veteran’s dignity or care is at stake. So, our bill also instills a new culture of accountability at the VA by improving training and strengthening its leadership.

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If you could identify one area where you feel health care delivery and/or treatment could be improved for veteran patients, what might it be? The Choice Program still needs work, which is why I’m working with Senate [Committee on] Veterans’ Affairs Chairman Johnny Isakson to streamline the community care programs and ensure that when veterans can’t access the VA, the transition to the private sector is seamless.

■■ “Whenever I meet with VA staff

in Montana, I’m just amazed at their passion and dedication they have for working for veterans.”

What are some of things that have impressed you the most about the VA? Whenever I meet with VA staff in Montana, I’m just amazed at their passion and dedication they have for working for veterans. Many VA employees are veterans themselves, and that creates the unique environment where you have veterans serving veterans. I think that creates a culture of comfort and understanding that is really important for veterans to have after they have put their lives on the line serving our country. In satisfaction surveys, veterans have consistently given high ratings to the VA for outperforming private-sector health care. Why do you think this is? I hear the exact same thing from Montana veterans every day. Medical staff and employees at the VA are some of the hardest-working folks around. Most of the VA’s staff are dedicated to serving veterans and the veterans know and feel that dedication when they go to the VA. That’s why veterans are there. And that’s also why instead of using VA resources to send veterans to the private sector, we need to make sure that VA facilities have all the resources they need to serve every veteran who walks in the door.

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A NEW ERA IN HEPATITIS C TREATMENT With a new class of drugs, VA’s clinicians are ramping up efforts to cure veterans of one of the most pernicious viral diseases.

n HISTORICALLY, MEDICAL SCIENCE’S FIGHT AGAINST infectious disease is an incremental affair, adding one small victory to another in the hope of giving humans the upper hand against microbial pathogens. Final conquests are all but unheard of. We’ve notched only one total victory so far: against the smallpox virus, which the World Health Organization declared eradicated in 1980. But medical research has now crossed another threshold that may one day be seen as significant as the discovery of the smallpox vaccine. Beginning in 2014, the U.S. Food and Drug Administration began clearing a new class of drugs, directacting antivirals (DAAs), for the treatment of hepatitis C. The 36

drugs work by blocking the hepatitis C virus’ ability to replicate itself in host cells. Hepatitis C is a communicable disease passed almost entirely through blood-to-blood contact, and about 15 to 40 percent of those infected fight off the infection within six months. The remaining 60 to 85 percent enter a chronic phase of disease in which the virus takes up permanent residence in the liver, inflaming and damaging it over a period of years. About two-thirds of chronic patients develop cirrhosis, an advanced liver disease that can develop into life-threatening conditions such as liver failure, hemorrhage, or cancer. Hepatitis C claims about 19,000 American lives annually.

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By Craig Collins

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These life-threatening conditions often take years, even decades, to manifest, and many Americans with it remain unaware they’re infected with hepatitis C virus (HCV). According to the U.S. Centers for Disease Control and Prevention (CDC), the vast majority – three-quarters – of the 3.5 million Americans infected with HCV are baby boomers, born from 1945 to 1965. The advent of DAAs marks a distinct transition. The old standard treatment for HCV – injections of the antiviral protein interferon, accompanied by oral intake of the drug ribavirin – is the standard no more. It was a notoriously grueling treatment that could last as long as 48 weeks, fraught with unpleasant and often debilitating side effects, and resulted in an overall cure rate of 50 to 60 percent. DAAs are pills that can be taken orally, one pill a day, for a period of 12 weeks (up to 24 weeks for some patients, such as those with decompensated cirrhosis), with fewer side effects and an astonishing cure rate of around 95 percent. Before DAAs were introduced, nearly 10 percent of American veterans were infected with the HCV virus – a rate of infection four times higher than that of the general population. The Veterans Health Administration (VHA), the largest single HCV care provider in the United States, is uniquely suited to treat HCV infection, and it has responded to the advent of DAAs with a robust screening program: So far, about 78 percent of veterans in the baby boomer cohort who are enrolled in VA benefits have been tested for the disease. Since the drugs were first made available, the VA has treated more than 90,000 patients, and continues to treat about 2,000 veterans every month. Maggie Chartier, Psy.D., M.P.H., psychologist at the San Francisco VA Medical Center and deputy director for VA’s HIV, Hepatitis and Related Conditions (HHRC) Program, said the introduction of DAAs “has changed everything. I feel really lucky to be part of the program at this time. It’s a totally different treatment than it used to be, not only in its effectiveness, but in that there are very few side effects.”

PHOTO BY MANDIE MILLS

BARRIERS TO HCV DIAGNOSIS AND TREATMENT

You might think the discovery of a pill that cures about 95 percent of people infected with HCV would spell the end of the disease. But the problem of HCV, and of connecting veterans to these new cures, isn’t simple. From the outset, the drugs presented a daunting obstacle for a nationwide medical system: They are among the most expensive oral medications ever produced, with a single pill’s wholesale acquisition cost ranging from $650 to $1,125. The average cost to cure a single patient, then, is estimated to be around $84,000. Last year, with help from congressional appropriators, the VA – which has received a significant discount on its DAA purchases – was able to announce that these costs would be no obstacle: The department’s policy would be to treat all veterans with HCV, regardless of cost or the progression of the

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■■ ABOVE: A blood test can determine if an individual has the

hepatitis C virus, and an additional blood test can show whether it is chronic hepatitis C. OPPOSITE: An illustration of the hepatitis C virus.

disease. Chartier and others see this new era as a window of opportunity to get as many veterans into treatment as quickly as possible. Even without resource constraints, this opportunity presents a new set of challenges, given the number of veterans – around 234,000 – with chronic HCV. The VHA can only provide care to the veterans enrolled to receive care – and only about 30 percent of U.S. veterans are enrolled in care. Despite the VHA’s impressive record of screening and treating, Chartier said, “We estimate that if all veterans in care who are at the highest risk for hepatitis C were tested, we would have approximately 15,000 undiagnosed veterans – 15,000 people we haven’t found yet who have hepatitis C. Compared to the 200,000 we started with, it’s actually a pretty reasonable number for us. And we’re doing a lot of outreach to try to get to those patients.” The VHA has been able to remove many restrictions on who is eligible for treatment for hepatitis C – those with ongoing substance abuse issues or advanced liver fibrosis are not automatically excluded, for example – but as the number of cures for veterans in care increases, so does the proportion 37

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

of those who, for a variety of reasons, remain essentially nontreatable. “Basically we treat everybody that we possibly can,” said Chartier, “but there is a group of patients who are going to be a challenge to treat.” A relatively small number of veterans have unstable or uncontrolled medical conditions in addition to hepatitis C – comorbidities – that exclude them from care, such as incurable liver cancer. Most of the comorbidities that keep people from HCV care, however, are psychosocial. While taking a pill a day for 12 weeks may seem simple to most healthy people, not everyone is able to do it, and failure to stick with the regimen risks making the virus drug resistant. Some patients, Chartier said, have psychiatric or substance abuse issues that make it difficult for them to adhere to the treatment – homelessness, an uncontrolled psychotic disorder, uncontrolled depression, or an untreated substance abuse disorder, for example. Because hepatitis C is a slowly progressing disease, Chartier said, there is also a significant number of veterans who simply choose not to get treated. “If you’re not drinking, if you’re not overweight, or aren’t taking other medications onboard that affect the liver, it’s very possible that you can have hepatitis C and it won’t actually be damaging your liver that much,” said Chartier. “So some people might make a decision not to get treatment until they get to a different disease stage.” The VHA estimates that as many as 30 percent of the veterans in care with HCV who are awaiting treatment are either unable or unwilling to begin – and so in recent years it has redesigned its system of hepatitis C care, to both reach out to these “non-treatable” veterans with HCV and to optimize its quality of care.

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■■ George Dooley, a Marine Corps veteran, talks with clinical

pharmacist Dr. Dana Pepe before picking up his final hepatitis C medication prescription. As of February 2017, Dooley was one of almost 1,200 veterans who had undergone the new treatment for hepatitis C at James A. Haley Veterans Hospital in Tampa, Florida.

MORE TESTING, BETTER TREATMENT

Armed with a new class of drugs that will cure nearly every veteran infected with HCV, and the resources to provide that cure to any veteran for whom it’s indicated, the VHA has redoubled its commitment to providing efficient and effective HCV care. First, the VHA has assembled a national Hepatitis C Resource Center, consolidating existing centers at several Veterans Integrated Service Networks (VISNs) – regional groupings of VA medical centers and clinics. Dr. Timothy Morgan, a hepatologist at the VA’s Long Beach Healthcare System, directs the center. “The primary purpose of the Hepatitis C Resource Center,” he said, “is to monitor and improve the care for hepatitis C across the entire VA system.” The primary program established to do that is the Hepatitis C Innovation Teams, or HITs. Each of the 18 VISNs now has a designated multidisciplinary team of experts examining hepatitis C testing and treatment at each VHA facility – and in some cases, at community-based outpatient clinics where hepatitis C care is delivered. Ideally, Morgan said, each HIT is led by a system redesign expert – a person schooled in what’s known as 39

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

■■ The Veterans Health Administration has launched an ad campaign

to encourage veterans to seek treatment for hepatitis C.

and kiosks, the campaign will place messages – stories told by veterans who have received hepatitis C care from the VHA – in both print and online publications. “We hope this will bring more people who may be eligible into VA care,” said Chartier, “and for those who may be more reticent about Hep C treatment, for whatever reason, maybe helping to motivate them to come in for treatment.” Chartier, Morgan, and their colleagues throughout VHA’s Viral Hepatitis Program see a rare opportunity – free of resource constraints, they at last have the capability to cure nearly every veteran with hepatitis C. The challenge will be to optimize the VHA’s clinical resources and its support system for care providers. “We have very motivated providers on the ground,” Chartier said, “who’ve really been struggling with treatment for years and years – because the treatments we had weren’t very good, and they were really hard to be on if you were a patient. And then all of a sudden here is this medication that can treat almost everyone who comes in the door, and it’s really easy to take, and we have the money to do it. It’s been this perfect nexus that will allow us to do amazing things. So, we’re trying to capitalize on that momentum and treat as many people as possible.”

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VA IMAGE

“implementation science” – who can maximize efficiency and effectiveness, and the team also includes clinical pharmacists, physicians, and nurses. Team composition varies across the VISNs, but each shares the same basic purpose: to identify barriers to testing and treatment at each facility, and to devise strategies for overcoming those barriers. Though they’re only a few years old, Morgan said, the HITs have already started to produce results. At the national level, team leaders have arranged for social workers to offer guidance in working with patients with psychosocial issues, such as homelessness or substance abuse. Among themselves, teams have shared best practices and successful approaches to problem-solving. “A recent example of that,” Morgan said, “was an electronic system that identifies patients who have not been screened for hepatitis C, and then automatically sends a letter to those patients. The letter says the VA recommends all patients born between 1945 and 1965 should be screened, and encourages them to bring the letter to their next VA appointment. That was one facility’s idea that’s now spread to other facilities.” In the last four years, as the HITs have been implemented across the VHA, the screening rate for hepatitis C in the baby boomer cohort has increased dramatically, from 65 to 78 percent. “My personal opinion,” Morgan said, “is that the HIT teams contributed to that.” The teams have also, he said, made the system of HCV care more standardized by exporting best practices and improving the performance at struggling facilities. While the HITs work to improve testing and treatment, the Hepatitis C Resource Center carries out several tasks to boost their efforts. It works with Population Health Services, in VHA’s Office of Patient Care Services, to collect, disseminate, and update data on how facilities are doing – dates of testing and treatment starts, for example. It conducts educational programs for patients, producing materials that inform them about the screening process and available treatments. For VHA providers, the Resource Center has produced a revised document of treatment considerations, providing an overview of which drug regimens are most appropriate for patients with certain genotypes of HCV. It has a designated liaison, one of the HIT team leaders, who focuses on getting care to veterans who live in rural areas, far from VHA facilities. “The traditional way medicine has worked is that a patient goes to their primary care doctor, and the primary care doctor will say, ‘You have hepatitis C,’ and send that patient off to a specialist,” Morgan said. “We’ve finally decided that model is not the way we want to run things. We’ve decided we’re going to be proactive and try to reach out to the patients where they are, and work with the doctors in those areas to get more patients into treatment.” The VHA recently launched an advertising campaign, targeting the 16 U.S. cities with the highest number of veterans with hepatitis C who are in VHA care and haven’t yet been treated. In addition to messaging on billboards, public buses,

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PREVENTING AND TREATING HIV n ALTHOUGH NOT IDENTIFIED AS SUCH AT THE TIME, the first official report on an unusual set of infections in five young, previously healthy, gay men was published by the U.S. Centers for Disease Control and Prevention (CDC) in the June 5, 1981 edition of its “Morbidity and Mortality Weekly Report” (MMWR). The story was picked up by the mainstream media and, by year’s end, 270 cases of severe immune deficiency had been reported among gay men nationwide – 121 of whom had died. On Sept. 24, 1982, the CDC named the disease AIDS (acquired immune deficiency syndrome) and released its first case definition: “a disease at least moderately predictive of a defect in cell-mediated immunity, occurring in a person with no known case for diminished resistance to that disease.” It was not until 1983, however, that scientists identified HIV (human immunodeficiency virus) as the cause of 50

AIDS – which actually is the terminal Stage 3 phase of HIV – although HIV did not become the official name for the virus until May 1986. Further research indicated treatment of HIV, when diagnosed early in Stage 1 (acute HIV infection), could both slow or prevent progression to Stage 2 and significantly reduce the chance of transmitting the virus to someone else. Stage 2 is marked by HIV inactivity – the virus is still active but reproduces at extremely low levels. Without medication, Stage 2 can last 10 years or more; with treatment, Stage 2 can last several decades, during which the patient can still infect someone else, although the rate of transmission is low. Stage 3 is full-blown AIDS. Without treatment, life expectancy in Stage 3 is typically three years, with death coming from a growing number of severe “opportunistic” diseases that the patient’s heavily compromised immune system is

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U.S. AIR NATIONAL GUARD PHOTO BY AIRMAN 1ST CLASS ANTHONY G. AGOSTI

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unable to fight. This is also the stage in which the patient is most infectious. As the virus’s nature, progression, and Stages 1 and 2 treatments became known, the U.S. military and Department of Veterans Affairs (VA) modified their responses. Once labeled a “gay disease” transmitted during sex – which is the highest risk – infection also can occur through exposure to infected blood via used needles, transfusions, open wounds, etc. In 1985, the military began testing all new recruits for HIV, rejecting those who tested positive; that is still the policy. Nevertheless, by 2009, the government estimated the HIV infection rate among active-duty personnel to be 0.15 to 0.20 per 1,000. While being HIV positive will block someone from joining the military, it is not cause for discharge if diagnosed after an individual is in uniform. “It currently blocks some OCONUS [overseas] assignments, varying by service. You cannot deploy into a combat zone and there is some variation among the services about where you can serve OCONUS. But those policies currently are being reviewed,” according to chief of Epidemiology and Threat Assessment at the U.S. Military HIV Research Program (MHRP) Dr. Paul T. Scott, M.P.H. During the first two decades of the fight against AIDS, many at-risk individuals avoided testing, which increased the disease’s spread. “There is still some stigma to being HIV positive,” Scott acknowledged. “We’re just beginning to formally look at that with the repeal of ‘don’t ask, don’t tell,’ which freed us of most restrictions of asking service members about the perceived and actual stigma and how that influences their care. We then use that to reduce barriers of any kind to access to treatment.” VA follows CDC testing recommendations – every veteran should receive at least one HIV test in his or her lifetime, more frequently if in a high-risk-factor group. The CDC also recommends universal testing for any group with an undiagnosed prevalence above 0.1 percent. While that is a low prevalence, the impact on public health is significant. Since they began testing, about 47 percent of all veterans accessing VA health care services have been tested. “Veterans in VA care have a high prevalence of HIV, so we recommend everyone get tested,” said Maggie Chartier, Psy.D., M.P.H., deputy director of the HIV, Hepatitis, and Related Conditions Program in the VA Office of Specialty Care Services. “At the end of 2016, we had 28,354 patients with HIV who had had at least one HIV visit in the previous calendar year. That was down slightly from 2015 and 2014. There had been an increase in 2012 – and an even bigger increase in 2013 – but, basically, the numbers have remained relatively stable. “Our 2009 state-of-care report showed 23,463 in 2008. The biggest difference was in 2009, when the law changed to remove the legal document for signed consent before we

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■■ ABOVE: Air National Guard Lt. Col. Kendall Sawyers, clinic nurse

for the 118th Medical Group, draws a blood sample from an airman on Sept. 17, 2016, in Nashville, Tennessee. The blood samples will be sent to Air Force laboratories and tested for HIV. Testing for the virus is a key component in preventing spread of the disease. OPPOSITE: A scanning electron micrograph of HIV-1 budding (in green) from a cultured lymphocyte. This image has been colored to highlight important features.

could test, which led to a huge increase in testing and thus more cases diagnosed.” As with the overall U.S. population, the highest risk group in the military and among veterans is African-American males. “There are significant differences by race and gender and age,” she added, “keeping in mind we only provide care for about 30 percent of all veterans. The HIV patients are mostly male – 97 percent – with African-Americans making up about half, whites 42 percent, 8 percent Hispanic/Latino, and less than 1 percent other groups. “We also have an aging cohort, which has caused some shift. The majority [of HIV-positive veterans] are over 45, older than those in the general population. For 2016, about 14 percent were between 40 and 49, only 10 percent younger than 40, 34 percent between 50 and 59 and 34 percent 60 to 69; the mean age is about 56.” Of all the developments in diagnosis and treatment of HIV/ AIDS, the most significant biomedical advancement in recent years has been PrEP – pre-exposure prophylaxis – according to Scott. “Behavioral risk reduction, condoms, test-and-treat, all a huge part of prevention, but HIV PrEP reduces individual risk by 90 percent or more by taking one pill a day – two antiviral drugs – that, when taken properly, is very effective at preventing HIV infection. But PrEP is not just a pill, it’s a whole program, including risk-reduction counseling at each visit and intensive follow-up every three months,” he said. 51

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“A lot of people are looking at different ways to take the meds – currently, it’s every day, combined with the PrEP follow-up. You screen for STDs [sexually transmitted diseases] as well as HIV, so you’re really bringing them into an overall STD prevention program through PrEP.” According to the CDC, PrEP can stop HIV from taking hold and spreading throughout the body. “It is highly effective for preventing HIV if used as prescribed, but it is much less effective when not taken consistently. Daily PrEP reduces the risk of getting HIV from sex by more than 90 percent. Among people who inject drugs, it reduces the risk by more than 70 percent,” the agency said. “There are guidelines from the CDC on how to manage a PrEP program, but there are some military-unique nuances. One of those is that service members move around a lot, so you have high turnover and high geographic variability,” Scott said. “We convened a working group [in May 2017] to look at all the issues to develop defense health issues procedures to meet the national HIV strategy goals, but also figure out how best to deliver it so service members have access wherever they are or go. “We’re just starting to explore how to transition service members from active duty to civilian life and how that affects PrEP. We’re very closely aligned with NIH [National Institutes of Health], the DOD [Department of Defense] HIV/AIDS Prevention Program [DHAPP], and the VA. In addition, we have a very large treatment program in Africa, such as the Joint West Africa Research Group, coordinated through AFRICOM [Africa Command], that covers all infectious diseases. We also work with CENTCOM [Central Command] on a project we’re initiating in Jordan and in coordinating the blood supply for anyone treated in a U.S. or coalition facility that sometimes has to use host-nation blood supply.” Mandated by Congress in 1986, MHRP has become a world leader in HIV vaccine research, threat assessment and epidemiology, HIV diagnostics, and cure research. MHRP is centered at the Walter Reed Army Institute of Research (WRAIR), U.S. Army Medical Research and Materiel Command. DHAPP, designated the executive agent for DOD HIV support for foreign militaries in 2001, is the DOD implementing agency for the President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003. Based at the Naval Health Research Center (NHRC) in San Diego, California, the program works to develop and implement culturally focused, military-specific HIV prevention, care, and treatment programs in more than 80 countries. Aside from Northern Command (NORTHCOM), which is responsible for the defense of North America, the geographic combatant commands (COCOMs) work closely with the U.S. military’s various HIV programs. European Command (EUCOM) works with PEPFAR and DHAPP to develop sustainable programs designed to eliminate HIV/AIDS as a threat to regional stability through

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MAJOR POINTS ON THE HIV/AIDS TIME LINE By the end of 1985, every part of the world had reported at least one case of HIV. In 1987, the United Nations General Assembly approved a resolution to mobilize all UN assets to fight HIV worldwide, placing the World Health Organization (WHO) in charge of the effort. The following year, the number of women with HIV/AIDS in sub-Saharan Africa exceeded men for the first time. In July 1990, Congress passed the Americans with Disabilities Act (ADA), which, among other things, prohibited discrimination against people diagnosed with HIV/ AIDS. In 1992, health officials identified AIDS as the No. 1 cause of death for U.S. men aged 25 to 44. In 1994, AIDS became the No. 1 cause of death for all Americans between 25 and 44. It held that position until 1996. By 1999, WHO announced HIV/AIDS was the fourth leading cause of death worldwide, No. 1 in Africa, and estimated there were 33 million HIV-positive people in the world and a total of 14 million had died from AIDS and related illnesses in just two decades. In January 2003, President George W. Bush announced creation of the President’s Emergency Plan For AIDS Relief (PEPFAR), a $15 billion, five-year plan to combat AIDS, with an emphasis on poor nations with a large number of infections. That program remains in place. In August 2009, VA sought to increase HIV testing among veterans by dropping the requirement for written consent. In October, the FDA approved the 100th antiretroviral drug to treat HIV. In 2013, UNAIDS announced new HIV infections had decreased by more than half in 25 low- to middleincome nations and the number of people receiving antiretroviral treatment worldwide had increased by 63 percent in the previous two years. However, the agency also reported 1.6 million AIDS-related deaths during 2012 and 2.3 million new infections, bringing the global total of HIV-positive individuals to 35.3 million – more than 1.2 million of those Americans. Source: www.hiv.gov

partnerships and interagency collaboration. Command efforts include counseling and testing to obtain HIV/AIDS status, planning appropriate intervention techniques for military members, and collecting data to establish baseline prevalence rates in the militaries. AFRICOM, the newest of the COCOMs, is responsible for U.S. military relations with 53 African countries, focusing on war prevention rather than warfighting by working with African nations and organizations to build regional security and crisis-response capacity. Africa has been especially hardhit by HIV/AIDS, which has significantly affected economic 53

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and political stability across the continent, degraded military medical readiness, and weakened the national security of individual countries. As a result, HIV/AIDS programs are a key component of AFRICOM’s security cooperation and humanitarian assistance activities. Pacific Command (PACOM) has been working to prevent the spread of HIV among military personnel in several Asian countries, including East Timor, India, Indonesia, Madagascar, Papua New Guinea, Thailand, and Vietnam. The Center for Excellence in Disaster Management and Humanitarian Assistance has been the primary PACOM organization implementing PEPFAR HIV efforts for militaries in the region, such as their partnership with the Royal Thai Army, which has led to the development of the HIV/AIDS Regional Training Center in Bangkok. The center provides education and training in HIV prevention, laboratory capacity building, and policy to military officers in the region. CENTCOM is tasked with deterring and defeating terrorism, strengthening regional stability, assuring regional access, and helping build partner-nation security self-reliance in the Middle East and Southwest Asia. That has included distributing medical supplies and HIV/AIDS educational and training materials to health clinics in the region. Southern Command (SOUTHCOM) has a primary mission to ensure the security of the United States, enhance western hemispheric security, increase regional stability through U.S. partner-nation relationships and improve the disaster response capabilities of partners in Central and South America. That includes efforts in HIV/AIDS prevention and treatment, such as the deployment of U.S. Navy hospital ships to train doctors and nurses in the latest approaches to AIDS/HIV. The National HIV/AIDS Strategy is a five-year plan, first released in July 2010, then renewed in July 2015, detailing principles, priorities, and actions guiding the collective U.S. national response to the HIV epidemic. According to the Department of Health & Human Services, “the updated Strategy reflects the work accomplished and the new scientific developments since 2010 and charts a course for collective action across the federal government and all sectors of society to move us close to the strategy’s vision,” which, in part, is to significantly reduce the number of HIV infections. On the home front, VA efforts to treat HIV-positive veterans recently turned to the growing technology of telemedicine for those in rural or remote areas without easy access to VA health care facilities. “We’re looking at using telemed in rural areas to provide care, both regionally and nationally. We’re trying to make access to care easier for those who have to make long drives to reach clinics. A lot of VA caregivers in rural areas don’t have a lot of experience with HIV, so telemed also allows HIV patients to receive specialty care. And in rural areas and small towns, many patients don’t want to be treated locally due to privacy considerations,” noted Jack Stapleton, M.D., director of Infectious Diseases, VA Office of Specialty Care Services. “A lot of telemedicine is done at a local CBOC [communitybased outreach clinic], where we have remote ways of doing 54

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U.S. NAVY PHOTO BY REGENA KOWITZ

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physical exams with amplified stethoscopes, for example, to do a reasonable exam without putting your hands on the patient. TelePrEP also is rapidly expanding. We’re looking at whether using TelePrEP, using SkypeTM, from a patient’s home is as effective as doing it in a clinic, although they still have to go to a facility for blood tests and such. Another aspect being looked at is whether people stay in the program as well as with other methods.” Chartier said telemedicine is one of several programs the VA is looking at to increase its health care services to HIVpositive veterans, as well as those with other medical needs. “Each facility has community-based outpatient clinics and telemed is part of how a lot of folks in rural communities are seen. CBOCs don’t have a lot of specialty care capability, but a patient coming into the clinic can go into a room with a video system and talk with HIV specialists elsewhere. That’s part of ECHO – Extensive Community Health Outreach. “If you have a physician with HIV expertise, that person would train a provider at another facility, who then would provide HIV care to local patients. We also have a homebased care program for those who find it difficult to come into a VA facility and that may be used with HIV patients in some remote areas.” As the HIV/AIDS epidemic approaches the end of its fourth decade, those responsible for the care of its military victims are cautiously optimistic about the future. “Many aspects are being studied. The two most exciting are cure research, looking at the latent infection of HIV. Until the last year or two, there were not a lot of studies that gave strong promise, but there are more recent ones that are, some involving gene studies and different ways of targeting latent cells,” Stapleton said. “Another important aspect is the

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■■ Rick Shaffer, Ph.D., director of the DOD HIV/AIDS Prevention

Program (DHAPP) at the Naval Health Research Center in San Diego, California, leads a discussion about the work the U.S. military has done in fighting the global HIV/AIDS pandemic during a World AIDS Day event on Dec. 1, 2016. DHAPP develops and implements culturally focused, military-specific HIV prevention, care, and treatment programs in more than 80 countries and is the executive agent of the President’s Emergency Plan for AIDS Relief.

use of longer-acting medications you only take once every three or four months. For people who have trouble taking meds regularly, this could be a huge advance. “We used to do a lot of clinical trials, but we don’t need to as much. We have about 800 HIV-positive patients here – between the VA and the University [of Iowa] – and 90 percent of our patients have a non-detectable viral load, where the virus cannot be detected in the blood. Nationally, we are toward the top of that. And that’s pretty remarkable, due to very effective drugs. Clearly, there is a need for ongoing development of new drugs for persistent viruses, but it’s only a small percent of patients who need that.” As to a cure … “I tend to be a sceptic. A year ago I would have said I didn’t expect to see it in my lifetime, but there is recent data using gene-editing techniques that are really exciting and have raised my optimism. I do believe it will take a novel, breakthrough approach to find a cure in the next 20 to 30 years – so maybe in my lifetime,” Stapleton replied. “HIV has a proviral DNA form that integrates into the human chromosome and very long-lived memory T-cells. These cells can carry a functional copy of the virus and, if activated, can restart the virus all over again. But if you can somehow target those cells, in theory, you could cure it.”

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DUKE UNIVERSITY PA PROGRAM AND THE NAVY CORPSMEN/ VETERAN CONNECTION By J.R. Wilson

n ON OCT. 6, 1967, the Duke University School of Medicine graduated three former Navy corpsmen from its new Physician Assistant Program, created two years earlier to support the nation’s too few primary care physicians, especially in low population areas. Dr. Eugene A. Stead, Jr., created the program, based on his experience with fast-track medical training during World War II, and chose former corpsmen for the first class due to their prior training and field experience in Vietnam. The Department of Veterans Affairs (VA) hospital in nearby Durham, North Carolina, became the first employer of physician assistants (PAs), starting with that initial class. Today, the VA remains the largest single employer of PAs in the country, with more than 2,300 employed by various veterans’ health care facilities nationwide and another 500 working as contractors. “VA’s PA workforce has expanded over the last 20 years, with an average growth rate of 3.8 percent per year,” according to Denni J. Woodmansee, director of Physician Assistant Services for the Veterans Health Administration, the medical component of the VA. “For the past three years, the PA occupation has been listed in the top critical occupational shortages by the VA OIG [Office of Inspector General] report. Major efforts are underway to enhance recruitment and retention of PAs to meet patient care demands. “Currently, 24 percent of the VA PA workforce are veterans, down from 31 percent in 2009. This may be due in part to a dilution effect from the very robust growth of the PA profession. In 2009, there were 75,000 certified PAs in the U.S.; in 56

2017, that number grew to 120,000. In addition, the profession has transitioned from being male dominated to a majority of PAs being female.” VA is working to tap into the first major increase in the veterans’ population since the end of the Vietnam War. “Efforts are underway to increase the number of veterans in the VA PA workforce by targeting [medical personnel] separating from the military services. According to 2017 National Commission on Certification of Physician Assistants data, 12,099, or 11.4 percent, of certified PAs are identified as veterans,” Woodmansee added. “Veterans come with excellent motivational skills, a comprehensive understanding of military culture, and a sense of comradery. “PAs are assigned to all patient care venues, from large urban medical centers to rural, remote clinics. In addition, PAs provide medical care in veterans’ homes through the Home Based Primary Care program and remote care through telemedicine. Most VA medical facilities across the country also participate in the clinical training of PA students by providing clinical rotations. In 2016, a total of 2,111 students received all or part of their clinical training in a VA medical facility.” Patricia McKelvey Dieter, PA division chief in the Department of Community and Family Medicine at Duke, said the Duke PA Program had close ties to the U.S. Coast Guard for its first 25 years or so. “Until the early 1990s, Duke educated all the PAs in the Coast Guard. Each year we chose two applicants to go through our program from the 1970s through the 1990s. We

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never had that kind of relationship with the Navy, although for the first seven or eight years of the program, many of our students were former Navy corpsmen,” she said. Duke began awarding graduating PAs a bachelor’s degree in 1972, then changed that to a Master of Health Sciences (MHS) in 1991. “When we converted to granting our student graduates a master’s degree, it may have been more difficult for Coast Guard personnel to qualify. In addition, other options for Coast Guard PAs became available in the ’90s,” Dieter noted, adding the change in degrees has been a problem for some veterans, as well. “A lot of military people take a few courses here, a few there, and eventually cobble it together to get a bachelor’s degree. That may or may not put them at a disadvantage, but there’s no hard or fast rule on that. We accept people based on academic potential. Our attrition rate is only about 1 percent, so if someone is admitted to our program, they almost certainly will graduate. And few of those who do drop out are veterans.” During her 30 years with the Duke program, she added, she could not remember a single class that did not include veterans, something they hope to increase once again. “We’re looking to recruit veterans in general, not just former medics or corpsmen, although they would be more

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■■ The Duke Physician Assistant Program building in Durham, North

Carolina. The program was created in 1965.

likely to apply here because they worked alongside PAs in the military,” Dieter said. “Duke really values its connections to veterans and all branches of the military, and we’re excited to see veterans in our applicant pool. “Not as many former Army medics or Navy corpsmen are coming here now as in the early days of the profession, where there was a larger pool of veterans from Vietnam. In later years, it became more attractive to people other than the military. Today, about 30 to 40 percent are already licensed in another health profession, mostly EMTs [emergency medical technicians], but we also have medical or nursing assistants and clinical research assistants.” It’s not easy to get into the program at Duke, which has graduated more than 2,000 PAs in the past half-century, nor any of the other PA training centers that have come into existence since 1967. “You need at least six months of patient care experience at the time of application, but most successful applicants have a lot more than that,” Dieter explained. “In an average year, we 57

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■■ Duke Physician Assistant Program 50th Anniversary celebration

reception gala at the Durham Convention Center in North Carolina on Oct. 3, 2015.

The Duke program grew steadily during its first few decades, eventually reaching 45 students per year. “About 12 years ago, our chancellor thought we needed to expand to meet the growing national need for PAs, so across about a 10-year period, we went from 45 students to 90 in each class, which lasts two years, overlapping – a first-year class and a second-year class. Today, we have 24 faculty and 15 staff members, all in our own building,” Dieter said. While there are no current plans for further expansion, she added, there is a renewed effort to recruit veterans into the program. “We really take notice of applications from veterans and value and appreciate those, knowing their life experiences will be valuable and they probably have strong tech skills. Veterans may have a greater predilection to practice in primary care than others. They tend to be people persons and love challenges – and one of the most challenging areas of medicine is primary care, because you can’t control who comes through your door. “When a PA is employed within a practice, that generally means there will be easier access and better communications

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DUKE UNIVERSITY PHOTOGRAPHY

have 2,000 to 3,000 applicants and only accept 90. And that’s not just Duke, but all PA programs.” Acquiring an MHS from Duke’s PA Program takes two years of intensive training across the medical spectrum. Although PAs work in primary care settings, most practice non-primary care specialties, with the ability to change specialties much more quickly than most other health care workers to meet changing patient care demands. That additional specialty training may come through mentorship by their collaborating physician or by attending a postgraduate residency program in a new specialty, although that is not required by the VA. However, their initial training as medical generalists enables PAs to work in geriatrics, pediatrics, or psychiatry without additional training, according to Dieter. “The PA Program courses include both basic – anatomy, histology, genetics, etc. – and applied sciences – clinical medicine, pharmacology, physical diagnosis, health systems organization, etc. It is similar in some ways to the first two years of medical school and the rotations PAs do are similar to what medical students do, as well,” she said. “Those classes are taught by PAs, physicians, Duke University medical staff, nurse practitioners, psychologists, etc. Some extended courses might have as many as 70 guest lecturers, not all of whom are Duke employees.”

DUKE UNIVERSITY MEDICAL CENTER ARCHIVES

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for the patient, who receives the same care. About a third of PAs work in primary care and in many cases, people would not have care if it weren’t for them. PAs are a key part of the VA’s goal to improve access, which is a critical need, so I would expect more VA positions to be available to PAs in the future.” A June 2015 study reported in the Journal of Physician Assistant Education surveyed all 173 PA program directors in the United States about recruiting, admitting, and training military veterans following announcement of the Helping Veterans Become Physician Assistants initiative by the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services. A summary of the report findings states: For the years 2011 through 2013, as compared to 2008 through 2010, there was an increase in the percentage of PA programs that actively recruited veterans, considered veteran status in the admission process, admitted veterans and contributed to their financial support. There was also an increased percentage of students with military experience matriculating into PA programs. However, barriers still exist for veterans seeking admission into PA programs, the most significant of which is academic preparedness for a graduatelevel PA program. Enactment of the Affordable Care Act in 2010, for the first time, recognized PAs as one of three primary care providers – physicians, nurse practitioners, and now PAs – and empowered them to lead patient-centered medical teams. PAs – whose training has long had team-based care at its core – practice interdependently in collaboration with other members of a patient’s health care team. A report by health care search firm Merritt Hawkins stated the demand for PAs increased more than 300 percent from 2011 to 2014. As of December 2016, there were more than 115,500 certified PAs nationwide who interact with patients an estimated 350 million times each year, according to the American Academy of Physician Assistants (AAPA). Founded in 1968 to represent PAs across the United States, the AAPA also is working to increase PA awareness, through its Caring for Veterans and Military Families Initiative, of how they can help meet the medical needs of the military and veteran communities. A dedicated website provides resources for PAs to utilize in caring for veterans and their families/caregivers and disseminates information about new research related to veterans’ health. But the academy believes the close relationships PAs build in the veteran community is an opportunity to go beyond traditional health care: “Recognizing that well-being is more than just physical health, the Joint Chiefs of Staff Warrior and Family Support program has discussed the ‘Model of Excellence’ as the necessary trinity for military veterans to successfully reintegrate into society. This includes access to health care, employment, and education. PAs can support the

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■■ PA students in 1968. The Physician Assistant Program at the

Duke University School of Medicine graduated in October 1967 three former Navy corpsmen among its first class. The VA hospital in Durham, North Carolina, became the first employer of PAs.

total wellness of military veterans by providing resources for employment and education in addition to being their health care provider.” At its annual conference in May 2017, the AAPA House of Delegates unanimously approved Optimal Team Practice, “a new policy intended to enhance the ability of PAs to meet the needs of patients and ensure the future of the profession in a changing healthcare marketplace,” according to an AAPA news release. “Passage of this new policy serves as a significant milestone for PAs,” said AAPA Immediate Past President Josanne Pagel, then president of AAPA. “While Optimal Team Practice may take some time to fully implement in all 50 states and U.S. territories, it will most certainly enhance the profession’s ability to help patients, especially in rural and under-served areas, and reduce administrative burdens on physicians. [It] gives PAs the foundation on which to pursue legislative or regulatory changes that will enhance the profession’s ability to meet our nation’s health care needs.” Also supported by the Physician Assistant Education Association, Optimal Team Practice will enable AAPA chapters in each state to pursue changes to state laws and regulations, such as removing requirements that PAs have and report to a supervisory physician in order to practice. It also calls for creation of autonomous state boards – with a majority of PAs as voting members – to license, regulate, and discipline PAs or, alternatively, for PAs to be full voting members of state medical boards. AAPA stated the effort resembles the full practice authority nurse practitioners have been pursuing and have achieved in 22 states and the District of Columbia. 59

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INTERVIEW

REP. PHIL ROE, M.D. Chairman, House Committee on Veterans’ Affairs

n REP. PHIL ROE, M.D., represents the 1st Congressional District of Tennessee. A resident of Johnson City serving his fifth term in Congress, he has a strong work ethic and is committed to working on behalf of the 1st District and the nation. A native of Tennessee, Roe was born July 21, 1945, in Clarksville. He earned a degree in biology with a minor in chemistry from Austin Peay State University in 1967 and went on to earn his medical degree from the University of Tennessee in 1970. Upon graduation, he served two years in the U.S. Army Medical Corps. He is chairman of the House Committee on Veterans’ Affairs. Additionally, Roe serves on the House Education and Workforce Committee. As a physician, Roe has become an active player in the effort to reform our nation’s health care system. He is the co-chair of the House GOP Doctors Caucus and a member of the Health Caucus. Prior to serving in Congress, Roe served as the mayor of Johnson City from 2007 to 2009 and vice mayor from 2003 to 2007. He ran a successful medical practice in Johnson City for 31 years, delivering close to 5,000 babies. Roe has three children – David C. Roe, John Roe, and Whitney Larkin – and is a proud grandfather. He is a member of Munsey Memorial United Methodist Church.

■■ Dr. Phil Roe, R-Tenn., is chairman of the House Committee on Veterans’

Affairs.

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HOUSE COMMITTEE ON VETERANS’ AFFAIRS PHOTO

By Rhonda Carpenter

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Veterans Affairs & Military Medicine Outlook: You’re a Vietnam veteran. Have you received medical treatment at a Department of Veterans Affairs (VA) facility? If so, what kind of care would you say you received? Rep. Phil Roe, M.D.: I am a Vietnam-era veteran who served near the DMZ [demilitarized zone] in Korea for about nine months and at the 121 Evac hospital in Seoul for about three months. I do not receive care through VA, but I did spend time training at a VA medical center in Memphis, served in the 2nd Medical Battalion – both at an evac hospital and treating patients in the field – and saw patients in consultation with VA during private practice. How have those experiences with VA influenced your service on the House Committee on Veterans’ Affairs and as a representative? Because of the experiences I’ve been fortunate to have with VA throughout my life, I think I have a unique perspective on the needs and strengths of VA. There are many things VA medical centers and clinics do second to none, but there are also areas where VA must improve. I believe we can utilize the expertise of the private sector while building on what VA has to ensure veterans receive the best care available. That is my top priority as chairman of the House Committee on Veterans’ Affairs. You co-sponsored the Department of Veterans Affairs Accountability and Whistleblower Protection Act that was signed into law on June 23. One aspect of the comprehensive law will give VA Secretary David J. Shulkin, M.D., more power to discipline, recoup bonuses, and fire employees for misconduct. Why was it so difficult to fire employees for bad behavior before? VA’s arcane civil service laws inadvertently protected bad apples within the department. When I first sat down with Secretary Shulkin, one of the questions I asked was what tools he needed from Congress to bring wholesale reform to VA, and he mentioned how his hands were often tied when it comes to disciplining and firing employees, even when there was clear negligence. In instances where VA has tried to take disciplinary action against an employee, the process was so administratively complex and lengthy that such action can take more than a year, often times being

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delayed indefinitely. A GAO [U.S. Government Accountability Office] study found that, on average, it takes six months to a year to remove a permanent civil servant in the federal government, though it often takes longer. Just last year, former VA Deputy Secretary Sloan Gibson testified at a hearing that it was too hard to fire bad employees at VA. We can’t expect VA to change course if the secretary doesn’t have the tools he needs to weed out bad employees to make room for new ones.

■■ “As chairman of the committee, I have a responsibility to both veterans and taxpayers. As I mentioned before, my No. 1 priority is ensuring our heroes have timely access to quality health care – period.”

In several reports, you stated you could be sure that the vast majority of VA employees serve and treat veterans with respect and dignity. Does the new law authorize recognition of good employees, with merit increases or awards for example? The law is focused on getting the bad employees, who have tainted the names of all VA employees for too long, out of the picture. I believe this will go a long way to improve morale within the department. Further, the law includes increased protections for employees who blow the whistle on wrongdoing within VA. Whistleblowers are incredibly important to exposing VA’s shortcomings, and I’m glad both President Trump and Secretary Shulkin have made this a priority for the administration. I also believe you can’t fire your way to success, which is why I’m glad the legislation just passed by the House and Senate to extend funding for the Choice Program includes provisions to ensure VA can hire and retain the providers needed to ensure veterans have access to quality care. This provision was unanimously passed out of my committee, and I’m confident it will improve VA’s hiring capabilities. 61

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is not practiced that way anymore. Some facilities probably need to close and be replaced with smaller clinics, but I understand the reality of what closing facilities could mean for the communities with large VA hospitals. That’s why I believe an independent panel should provide an honest review of VA’s assets and give Congress and the administration the opportunity to consider the recommendations. Some will say this is a step toward privatization or something that will harm veteran care, but the reality is this panel could very well find that certain regions need more facilities, not fewer. With that said, we’ll never know until we put in the work to see which regions need more resources and which regions have facilities too large for their veteran population. I’m confident we can get this review done in a way that will increase veterans’ access to care, which I believe is everyone’s goal.

■■ Rep. Phil Roe, fourth from left, made an

unannounced visit to the Washington, D.C. VA Medical Center on July 19, 2017, to discuss the facility. On July 12, 2017, the House Committee on Veterans’ Affairs held a hearing in which Roe called for a review and realignment of VHA capital assets.

HOUSE COMMITTEE ON VETERANS’ AFFAIRS PHOTO

The VA has identified more than 1,100 facilities nationwide that are underused or vacant properties that could be closed, saving approximately $25 million each year. In a White House briefing in May, Shulkin said that under the National Realignment Strategy, the VA may seek to close some facilities. Is your committee considering shuttering some VA facilities? And if so, what would be the disposition of them? As chairman of the committee, I have a responsibility to both veterans and taxpayers. As I mentioned before, my No. 1 priority is ensuring our heroes have timely access to quality health care – period. The Commission on Care made a recommendation to review VA’s assets, and that’s absolutely something the committee is working toward. VA is currently building infrastructure based off a 1970s model of care, building large, 500-bed inpatient hospitals, but the reality is medicine

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DR. PHIL ROE TWITTER FEED PHOTO

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

How will the Veterans Choice Program Improvement legislation passed in April affect the Veterans Choice Program? In what ways did the Veterans Choice Program need to be improved? What will these changes mean to veterans and veteran patient caregivers? Right now, the committee is looking at several ways to improve the Choice Program and consolidate community care. I don’t think you’ll find anyone in Congress who will say the Choice Program rollout went as well as expected. The thing is, veterans have been receiving care outside VA for many years, largely due to the fact that VA doesn’t provide some of the services veterans need. The VA waitlist scandal obviously increased the number of veterans seeking outside care, but I think we can work toward a consolidated community care network that capitalizes on the strengths within VA and the private sector. Again, to me, it’s all about veterans’ access to timely care and improving their VA experience, so right now we’re looking at a lot of different ways to get this done in a fiscally responsible way. What do you see as the biggest hurdle facing the Department of Veterans Affairs today? With an agency as large as VA – the second-largest department in the federal government, second only to the Department of Defense – it’s going to take time to make the changes needed to bring the department into the 21st century. The federal government historically evolves much slower than the private sector, but the more than 9 million veterans who access care through VA are counting on us to get this right, and to get it right fast. I definitely think that’s the biggest hurdle facing VA, but I don’t think it’s a hurdle we can’t overcome.

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Where do you see the VA in five years? Ten years? I know where I’d like to see VA. I think some at the department have lost track of VA’s core mission: to care for the men and women who [have] borne the battle and their families. I know Secretary Shulkin is dedicated to getting the focus back on that mission, and I commend him for his efforts. In five and 10 years, I’d like VA to have regained the trust of America’s veterans, and for our nation’s heroes to have confidence in the fact that – after the oath and promise they take when they put on the uniform – our country will keep its promise to care for them and provide for their needs. I’d like VA to become a leader in medical innovations and treatment, and to continue its leadership in training medical providers. I’d like to see a transformed information technology system that allows easy access to claims, medical records, and education benefits. There are so many things VA does well, and I strongly believe refocusing on the department’s mission and doing whatever it takes to align the current veteran experience with that mission will transform the department into the agency it can and should be.

■■ President Donald Trump turns toward Rep.

Phil Roe to hand him the pen with which he signed the Veterans Choice Program Improvement Act on April 19, 2017.

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

CHAPLAINS PLAY A KEY ROLE IN PROVIDING SPIRITUAL AND COMPREHENSIVE CARE

n FOR VETERANS RETURNING FROM IRAQ AND AFGHANISTAN, the transition back to life in their communities is often a struggle. While some face physical challenges, others deal with emotional scars from combat as evidenced by the increased reporting of post-traumatic stress disorder (PTSD) compared with past conflicts. The Department of Veterans Affairs (VA) is responding with a multi-layered approach – one that often views the role of chaplains as a key element in a comprehensive team effort. “Whether they function as Roman Catholic, Protestant, Jewish, Muslim, or Buddhist representatives, chaplains care for the whole person,” said chaplain Michael McCoy, director of the National Chaplain Center (NCC) of VA. “The chaplain is there to provide spiritual care in any way they can.” 64

In VA medical centers, chaplains typically serve as part of a patient care team as they make regular rounds to meet with individuals and participate in patient-care conferences alongside nurses and social workers. In other settings, they may provide one-on-one counseling – even by videoconference – to serve veterans where they live. In addition, they increasingly work with community clergy to learn about key symptoms of PTSD or depression, focusing on issues from substance abuse to suicide prevention. “Even though I’m a rabbi, I’m there to take care of a human being, regardless of religion,” said Lowell Kronick, associate director for chaplaincy education at the NCC. “It’s one human being taking care of another human being. We are there to work with all patients.”

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U.S. ARMY RESERVE PHOTO BY BRIAN GODETTE; USARC PUBLIC AFFAIRS

By Charles Dervarics

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

VA PHOTO

CHAPLAIN ROLES AND ASSIGNMENTS

More than 800 spiritual leaders are part of the VA’s chaplain service, and they work in VA medical centers and outpatient clinics. Most VA centers have multiple staff, including clinical chaplains and a lead chaplain, McCoy said. Often assigned to a certain floor or wing, chaplains typically participate in medical rounds – getting to know patients – and attend patient care conferences. At these conferences, chaplains are part of a team that includes a care manager and social worker, where they discuss individual patients and how best to serve them. Chaplains typically also do a spiritual assessment of a VA patient. “A patient may not be religious but may require the use of a chaplain,” McCoy said, and one key ingredient is that chaplains emphasize spiritual care but not necessarily religion. “A chaplain does not force religion on anyone,” he noted. But chaplains also will conduct services in their religion at a VA chapel, with service times varied during the week. Inside a VA hospital, the typical chaplain may see 20 patients per day, according to Kronick. “It’s not a pulpit, it’s a medical setting,” he noted. Even if veterans have not been typically religious in the past, “They may feel more of a link with chaplains.” Most chaplains are full time, though there are some parttime staff in some communities. Contract or fee-based chaplains may serve as extra support to full-time chaplains or provide religious ministry to veterans belonging to small faith groups. At any time, there also are about 150 resident student chaplains training at VA medical facilities and participating in clinical pastoral education. The chaplain program is open to U.S. citizens with a Master of Divinity degree and an ecclesiastical endorsement. Candidates also should have multiple units of clinical pastoral education and three years of pastoral experience. “As VA chaplains, we are different from community clergy,” Kronick noted. “We’re not there to proselytize and we’re not there to push religion. It’s not a pulpit – it’s a medical setting. Whatever is going on, we are there to work with the patient.” To lead this effort, the VA relies on the NCC in Hampton, Virginia. Led by McCoy, the center works to empower VA chaplains and sets policies and procedures for the spiritual and pastoral care of veterans. The center also: ■ Advises on all levels of chaplain staffing and management throughout the VA; Provides comprehensive orientation and training for ■ chaplains; ■ Manages award and recognition events, including twice-ayear ceremonies to recognize outstanding chaplains; and ■ Helps integrate spiritual care into the “whole-person care” philosophy of the Veterans Health Administration. “We represent as many religions as we have veterans,” McCoy said. “Chaplains are a secret weapon in the VA because they can reach across all aspects of our veteran population.”

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■■ ABOVE: Michael L. McCoy, director of the VA’s National Chaplain

Center. OPPOSITE: Bibles and other reading material line a desk at the Rural Clergy Training Program (RCTP), a train-the-trainer seminar sponsored by the U.S. Army Reserve Command chaplain office, in collaboration with the VA National Chaplain Center, at the Family Readiness Group Convention Center, Pope Army Airfield, North Carolina, March 2-3, 2016. The RCTP training seminar brought together representatives from all three military components from across the country into a learning environment designed to help facilitate the education of community clergy about how they can support veterans and their family members through the readjustment process.

But the job of chaplain also is undergoing subtle changes, and one high priority is to provide more options to veterans who live in remote areas far from VA hospitals. According to the VA’s Office of Rural Health, there are 2.9 million rural veterans who account for 33 percent of all those served by the VA health system. Given this trend, the VA has bolstered its telehealth program, which includes the designation of “tele-chaplains” who can provide long-distance support. To initiate this remote contact, a chaplain and veteran typically communicate via both audio and video in real time to discuss issues and challenges. “It’s a way for the veteran to be at home and talk to a chaplain,” McCoy said. Instead of a veteran – or a chaplain – driving many miles for a counseling session, technology brings the two individuals together remotely. “Veterans can receive counseling while they’re sitting at their kitchen table. It can be a really valuable tool.” Of the approximately 800 chaplains in the VA, more than 150 are women as the VA seeks to better serve the needs of 65

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■■ Command Sgt. Maj. Jim Wills, U.S. Army Reserve command

GREATER ROLE IN MENTAL HEALTH

sergeant major, and Col. Alan Pomaville, U.S. Army Reserve Command (USARC) chaplain, sign the “Shoulder-to-Shoulder” pledge and suicide-prevention initiative at USARC headquarters, Fort Bragg, North Carolina, March 2, 2016. Shoulder-to-Shoulder is an initiative where each USARC team can help protect the life of every soldier in their unit, creating and continually reinforcing a blueprint of personal connections whereby soldiers and their family members can easily reach out for help.

Another major trend is for chaplains to gain special certifications beyond their religious training. For example, some are gaining certification in areas such as mental health, where they can work alongside psychologists and social workers in the treatment of veterans with PTSD, depression, and other conditions. Two factors help to drive this development, Kronick said. First, some rural areas have few mental health professionals; in addition, veterans may believe there is a stigma associated with reaching out to mental health professionals. He said VA chaplains can serve a valuable role by reaching out and listening to veterans and, where needed, encouraging them to seek additional counseling. Aside from physical problems, veterans also may experience what Kronick describes as “moral injury.” Looking back on his or her service, a veteran may regret actions taken in tense situations in an environment where it can be hard to distinguish the enemy. “They may feel guilty about something

they did in combat,” he said. “When they return home, they say, ‘I’m not the person I used to be.’” In these situations, chaplains may counsel veterans to deal with these moral injuries by giving back and volunteering in their communities. In some cases, the goal is to “get reintegrated into the community where you can do good works,” Kronick said. However, the guilt may be so severe that a veteran would benefit from additional counseling from mental health professionals. Chaplains also interact with the VA’s Office of Suicide Prevention, which seeks to address a national trend in which the number of suicides among veterans exceeds the rate in the U.S. population. All of these factors figure into the growth of chaplains with certification in mental health issues. Kronick said the goal is not for chaplains to diagnose

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U.S. ARMY RESERVE PHOTO BY BRIAN GODETTE; USARC PUBLIC AFFAIRS

female veterans. “The VA has a relatively short history of caring for women veterans,” McCoy said. “That’s why it’s important to have chaplains who are skilled in dealing with women’s issues, from health care needs to successful return to the community or the workforce.”

WARRIOR TO SOUL MATE FACEBOOK PHOTO

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

PTSD and depression but to recognize the symptoms and encourage referrals. “We are creating bonds between chaplains and mental health professionals,” Kronick said. While in the past the two groups may have had little communication, the goals now are for both groups to work collaboratively when possible. “We want to break down barriers,” he said, so that veterans can turn to a variety of individuals if they want counseling. This new approach also has spurred the NCC to develop an outreach program to work with community clergy not affiliated with the VA. These clergy may have informal contact with veterans in their communities. “We’ve found that veterans return to their original communities and are much more likely to seek out clergy – including community clergy – more than any other professional,” McCoy said. In response, the center established the Community Clergy Training Program (CCTP), which consists of short-term training sessions to educate local, non-VA clergy about the challenges facing returning veterans. These sessions are a mix of face-to-face training, online or video presentations, and other resources. As with VA chaplains, the goal is not for these clergy to diagnose veterans but to help recognize symptoms that may warrant follow-up. “The goal is to provide community clergy with the tools they need to help veteran families when they are facing struggles emotionally and mentally,” McCoy said. So far, 18,000 community clergy nationwide have participated in workshops. “Veterans may feel safe coming to a house of worship or a community of faith to talk about these things because they feel a sense that it’s confidential and that no one will know they are going to a mental health provider,” Kronick added. Yet there is also the potential for community clergy to encourage veterans to receive treatment. With a small amount of training, these clergy can “provide a warm handoff” to the VA so a veteran can get additional help. In fiscal year 2017 alone, the CCTP added 28 VA chaplains to its training team to deliver workshops to community clergy – primarily in rural areas. The interactive training covers four major topics: military culture and the wounds of war; pastoral care with veterans and their families; mental health services and referrals; and building community partnerships. “Our rural veterans don’t come to a VA facility. They’ll come first to clergy in the community,” according to Kronick. “We’re trying to train all chaplains to be able to identify signs and work with community chaplains.” The VA has identified this program as a rural promising practice, and more information on the program is online at www.patientcare.va.gov/ chaplain/clergytraining/. OTHER FOCUS AREAS

In addition to mental health, the NCC has increased its work in supporting the families of veterans. Such families often

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■■ A couple participating in the VA’s Warrior to Soul Mate program.

face undue stress: A study from Brigham Young University states first marriages of military veterans are 62 percent more likely to end in divorce compared with the national average. One key initiative in response is a marriage enrichment program called “Warrior to Soul Mate” in which chaplains work with couples to support and restore their relationships. “There can be problems in sustaining marriages when veterans return from service. We’re concerned about that and designed this program,” McCoy noted. Based on discussions that began in 2008, the Warrior to Soul Mate program relies on a curriculum for couples that deals with key issues such as emotional literacy, conflict, communication, stressful relationships, and intimacy in stressful relationships. At some point in the program, couples are strongly encouraged to attend a weekend workshop at a remote location. “We’ve had people say they were on their way to divorce court but decided to try the weekend and were able to put their marriage back together,” McCoy said. “We believe we’re getting good outcomes from this program.” More information on this initiative is at training.pairs.com/docs/VA_ Support.pdf. Other innovations cited by chaplain leaders include home visits where feasible as well as chaplains gaining certifications in areas such as palliative care and hospice care for those with significant health issues, according to Kronick. Certification in substance abuse prevention is also growing as chaplains seek to provide comprehensive support. “We want our chaplains to have specialized training and stay current. Wherever the patient is, that’s where we go,” he said. “Our goal is to provide care for the whole person.” 67

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CARDIOLOGY CARE ADVANCES IN THE VA By Gail Gourley

n WITH HEART DISEASE THE LEADING CAUSE of death in the United States and the No. 1 reason for hospitalization in the Department of Veterans Affairs (VA) health care system, the importance of cardiac care cannot be overstated. Cardiovascular diseases involve a range of disorders including coronary artery disease, congestive heart failure, hypertension, stroke, and structural heart disease. Historically, the VA has demonstrated consistent focus on these problems, both clinically and with research efforts, and through an array of current advances and innovative approaches continues its commitment to delivering exceptional cardiology care to veterans. “I would use the descriptive terms comprehensive, dynamic, exciting, and evolving,” said Sunil V. Rao, M.D., section chief of cardiology at the Durham VA Medical Center and associate professor of medicine at Duke University Medical Center in Durham, North Carolina, in portraying the current state of cardiology care for veterans. “I think that’s a credit to the providers, a credit to the current administration of the VA, and a credit to the veterans, because they’ve demanded better care, and I think the VA has responded to that.” According to Richard Schofield, M.D., national program director of cardiology in the VA Office of Specialty Care, “Generally speaking, cardiologists in the VA are adopting new treatments in the same manner and along the same time lines as would be seen in academic medical centers and in the private sector. In this regard, the VA benefits from its close and ongoing relationship with over 100 academic medical centers, which allows for sharing of faculty physicians and trainees, and which promotes the early adoption of medical advances.” One example Schofield cited of the VA’s early adoption of cardiology advances is the radial artery access method for 68

cardiac catheterization, a procedure in which a long, thin tube, or catheter, is inserted into an artery and threaded through the vessel to the heart for diagnosing and treating cardiovascular conditions. Rather than the traditional approach through the femoral artery in the groin, radial artery access is through an artery in the wrist. Schofield noted that this method is increasingly recognized as a quality of care indicator in interventional cardiology, and that the VA has a higher rate of use, 44 percent, than the private sector at 25 percent, as reported in the 2014 American College of Cardiology CathPCI Registry. “The traditional approach to doing heart catheterization to diagnose and treat heart disease has always been through the femoral artery in the groin,” explained Rao. When cardiac catheterization was first developed, he said, the instrumentation was quite large, but since then, “the equipment has become significantly miniaturized; it’s much smaller now than it was 40 years ago when it was first developed.” That change allows for catheter insertion through the radial artery in the wrist, a much smaller and more superficial blood vessel than the femoral artery in the groin, which reduces bleeding risk, the major complication from cardiac catheterization. Rao said the “golden era” for the radial artery approach has been in the last seven to eight years. In that time, large studies of 7,000 to 8,000 patients randomly assigned to either the traditional approach of doing cardiac catheterization through the groin, or the newer way through the wrist, showed the rate of bleeding and vascular complications from the radial artery approach was 70 percent lower, “with absolutely no sacrifice in the treatment efficacy.” There are additional advantages to this method, which all contribute to increased patient satisfaction. Rao emphasized,

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■■ Marine Corps veteran

VA PHOTO

Paul Lehr visits the surgical team one week after undergoing a successful transcatheter aortic valve replacement (TAVR) procedure at the VA Ann Arbor Healthcare System’s Hybrid Open Heart Surgical Suite/Catheterization Laboratory. TAVR is an alternative to traditional cardiothoracic surgery and is used for treating structural heart disease, such as aortic stenosis, which is common among older patients in the VA population. The VA has embraced new advances in cardiac care like TAVR.

“Patients tell us exactly why they prefer the radial artery approach.” One reason, he explained, is that it eliminates the requirement for patients to lie flat on their back for four to six hours, necessary after the traditional femoral artery approach. This allows recovery in a more comfortable position post-procedure, especially helpful to those with arthritic conditions or back problems. It also facilitates early ambulation and use of the bathroom in a usual way, instead of the challenge of bedpans or urinals while lying flat. Patients also report much less discomfort at the insertion site using the radial artery, Rao said, so they’re able to ambulate more easily and recover faster at home. Rao elaborated on the VA’s more rapid adoption of the method. “Some small pockets of practitioners started adopting the radial approach,” he said. “We were one of them here in Durham way back in 2006 because we read the literature and said, ‘This is a way for us to increase patient comfort, reduce complications, and increase patient satisfaction, and because the recovery process is so much faster, maybe we could even treat more veterans coming through our VA.’ So we adopted it, and we started teaching other people how to do it, and it turns out that in the last probably 10 years, there’s been an influx of cardiologists in the VA system who are very forward thinking and were already using this approach.” Rao said that while the VA system as a whole is using the radial approach at a rate of 44 percent, the frequency at the Durham VA Medical Center is much higher at 96 percent. Using the VA mechanisms for funding research, Rao said, “We’ve studied some of the barriers that physicians and

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programs may have to adopting the radial artery approach, and the biggest one, really, is lack of training. So the VA has supported a large-scale national program to train physicians and cardiac catheterization laboratories in doing the radial artery approach. And we’re hoping to launch that [program] this fall in an attempt to even further encourage VA centers to adopt the radial approach.” Rao said that the use data over time was further supported by studies, including a 2008 paper looking at just privatesector procedures. “There’s a large database of private-sector procedures housed at the American College of Cardiology, the professional society for cardiologists,” he said, “and we looked at over 600,000 procedures done between 2004 and 2007 in the private sector. It turns out that the rate of radial artery approach during that time period was only 1 percent. So 99 percent of the procedures done outside the VA were being done using the traditional femoral approach. “So we then looked at it in the VA system a few years later,” Rao continued. “And while early on, again during that same time frame, the rate of radial artery approach in the VA was very low, around 1 percent, it has dramatically increased, I think because of the publication of these studies showing that it was so much safer. So we do have a time line of the adoption rates. Both the private sector and the VA started very, very low. If you say that time zero is 2008, here we are in 2017 and the VA is at 44 percent and the private sector is at 25 percent. So we’ve far outpaced the private sector, and I think it’s because the VA is very focused on a patient-centric approach to cardiology care.” Schofield described another significant area of progress as the development of dedicated structural heart disease 69

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intervention programs across the VA. “These important programs allow for close collaboration between surgeons and cardiologists, and the performance of complex catheterbased interventions like transcatheter aortic valve replacement (TAVR) and mitral valve clip procedures,” he explained. In describing structural heart disease, Rao said, “This is not dealing with blockages in the blood supply to the heart muscle and the coronary artery. This is dealing with valvular disease, valves in the heart that either leak or don’t open well enough; for example, aortic stenosis, which is a very common disease among older patients, particularly in the VA population. “The traditional way to treat that has always been through cardiac surgery that involves sternotomy, cutting the chest open,” he said. “Many patients are not candidates for that surgery because they have so many other illnesses.” Rao said that about 10 years ago, a technology was developed to enable valve replacement through a catheter. “These catheters are very large, so we still have to use the groin for those,” he said, “But this does avoid the patient having to get their chest cut open, and very large studies have shown that doing the catheter-based valve replacement improves survival over just medical therapy.” Previously, patients who were not candidates for surgery could only be treated with medication, Rao said. “Now, we have an option where we can actually replace their valves through a non-surgical catheter procedure with a hospital length of stay somewhere between three and five days, and one that reduces mortality from valve disease by up to 50 percent … And the VA has embraced this as a way to treat our veterans.” Currently, eight VA sites perform TAVR procedures, with that number expected to double over the next one to two years

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■■ TOP: Richard Weaver, registered cardiac invasive specialist (foreground) and Dr. Izzat Shah provide veterans advanced cardiac catheterization care at the Wilkes-Barre VA Medical Center. The majority of cardiac catheterizations performed at the Wilkes-Barre VAMC are radial catheterizations. The VA has a higher rate of use of this method than the private sector. ABOVE: The Wilkes-Barre VAMC’s state-of-the-art Cardiac Catheterization Suite features cutting-edge technology.

as additional VA facilities upgrade their operating rooms to make them compatible for complex procedures like TAVR. Rao said there are other procedures coming up very rapidly in structural heart disease, one of which is left atrial appendage occlusion. “This is for patients who have atrial fibrillation, an abnormal rhythm of the heart where the risk is stroke,” he explained. “Because the blood is not flowing through the heart normally, it pools in the heart. It can form 71

■■ TOP: A surgical team carries out a TAVR procedure. Thanks to

TAVR, many patients who are too high risk for traditional open-heart surgery now have an option for treatment of structural heart disease. Hospital stays for TAVR patients are shorter on average than those for traditional open-heart surgery patients, and recovery is faster. ABOVE: A medical illustration of the left side of the heart shows the left atrial appendage, the cul-de-sac-shaped area protruding from the left atrium (upper chamber). Left atrial appendage occlusion is a procedure in which a catheter is used to tie off that area, which can harbor blood clots that can lead to strokes in patients with atrial fibrillation.

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PATRICK J. LYNCH, MEDICAL ILLUSTRATOR; C. CARL JAFFE, MD, CARDIOLOGIST

blood clots, and those blood clots tend to ‘live’ in the left atrial appendage, where they can break off and cause strokes. “We’ve traditionally treated those patients with blood thinners,” Rao continued. “Some patients are not candidates for blood thinners because of a variety of different comorbid conditions. There’s a new technology now that allows us to actually non-surgically, again in the cath lab, using a catheter without a surgical incision, to tie off that left atrial appendage and basically seal off that area that gets blood clots. That’s a structural heart disease intervention that’s being introduced into the VA.” The VA has also been a pioneer in the area of cardiovascular clinical data registries through its development of the VA Cardiovascular Assessment, Reporting and Tracking (CART) program. The CART program features real-time patient data entry of all VA patients undergoing cardiac catheterization procedures in a process that is fully integrated into daily workflow in the Computerized Patient Record System, the VA’s electronic health record. This allows rapid and ongoing assessment of quality of care in all of the VA cardiac catheterization laboratories. It also has contributed a number of important research findings in the cardiovascular scientific literature. Additionally, the VA administers one of the world’s largest remote monitoring programs for cardiac implanted electronic devices. The National Cardiac Device Surveillance Program (NCDSP) maintains a database of all veterans with implanted pacemakers and defibrillators followed in the VA system, coordinating remote monitoring of 45,000 patients. Remote monitoring has been shown to increase access to timely cardiology care and improve clinical outcomes in patients with these devices. The NCDSP also tracks implanted devices or leads that are subject to Food and Drug Administration (FDA) or manufacturer recall or clinical safety alerts. Another new development is the rollout of hemodynamic monitoring programs for chronic heart failure, made possible by the recent FDA approval of an implanted pulmonary artery pressure sensor that wirelessly transmits pulmonary artery pressure data on ambulatory outpatients with this diagnosis. Schofield explained, “Use of this ambulatory pressure data is increasingly believed to be advantageous in the titration of oral heart failure medications, and by doing so, the rates of heart failure re-hospitalization may be reduced.” Heart failure is a very common problem, not just for Americans in general, Rao said, but for veterans, adding, “The No. 1 Medicare diagnosis in cardiology is congestive heart failure,” a condition resulting from the heart’s inability to maintain adequate blood circulation. He explained that in congestive heart failure, the pressure inside the heart builds up to the point where the blood, rather than flowing smoothly through the heart, pools and causes fluid buildup in the lungs. That pressure can be measured, traditionally with a procedure done through the arm in the cath lab. Medications can be adjusted based on those measurements.

VA PHOTO

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

DORN VA PHOTO

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

“This technology now allows us to implant a monitor inside the heart, in the pulmonary artery, that will continually monitor that pressure and relay that information back to our clinic, allowing us to actually preempt patients from having to come to the hospital,” Rao said. If the monitoring system relays information that pressures are increasing, he added, “we can call the patient and say, ‘Your pressures are starting to go up. It looks like you probably need to increase your diuretic medicine,’ and we can keep an eye on that pressure to make sure that it comes back down. That allows patients to stay at home, in a state that we call euvolemic, or avoiding having fluid build up in their lungs.” Rao stressed that the VA has been proactive about getting this technology into its system. Currently, the VA has more than 15 sites that are implanting this device in heart failure patients. Rao pointed to one more example of the VA’s innovative approach to cardiology care. “This is a new spin on an old reliable treatment, cardiac rehabilitation, which has been shown to be very beneficial for patients who have heart failure or a recent heart attack,” he said. “The challenge in the VA system has been that because the infrastructure, the number of VA hospitals, is relatively constant, we have not had an opportunity to prescribe cardiac rehabilitation to as many patients as we’d like.”

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■■ Navy veteran Danny L. Henderson visits William Jennings Bryan

Dorn VA Medical Center, in Columbia, South Carolina, to strengthen his heart after surgery while award-winning cardiology nurse Yvette Twum-Danso, RN, MSN, CCRN, tracks his progress. Such cardiac rehabilitation treatment for veterans has typically taken place in VA facilities, but the VA has instituted home-based cardiac rehabilitation programs so that more patients can experience the benefits of the treatment.

So the VA has instituted home-based cardiac rehabilitation programs, he said. “There are several centers now that have a program, including Durham, where we identify patients who are candidates for cardiac rehabilitation, do their evaluation before they’re discharged from the hospital, and send them home with a pedometer and a tablet that allows us to videoconference with them. This allows them to do their cardiac rehabilitation at home, through monitoring from the VA facility.” Regarding the VA’s resourceful approach, Rao said, “I think that’s a very creative way of introducing a simple, and yet incredibly effective treatment.” 73

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VA PHOTO

VA FOCUSES ATTENTION ON WOMEN’S CARDIAC HEALTH Heart disease is the leading cause of death for women in the United States, and approximately the same number of women and men die each year from cardiovascular causes, according to 2013 figures from the Centers for Disease Control and Prevention. Those facts, combined with Department of Veterans Affairs (VA) data showing the number of women veterans on the rise, reinforce the importance of the VA’s efforts directed toward women’s cardiac health. For example, the VA has partnered with the American Heart Association’s “Go Red for Women” campaign in order to improve awareness among both veterans and providers regarding heart disease in women. Each year in February, the VA coordinates events across the country in local VA medical centers, as well as in the VA Central Office, for “Go Red” day. Events include healthy cooking demonstrations, wellness and exercise classes, and presentations on heart disease in women. In another example, VA Women’s Health Services has published a VA document, “State of Cardiovascular Health in Women Veterans.”1 According to the publication, it’s the first in a planned series of reports. It evaluates cardiovascular risk factors, conditions, and procedures occurring in VA outpatient care in women and men veterans. Key findings include the rapid growth of the women veterans’ population, the shifting age distribution of that population, and the high frequency of cardiovascular risk factors in women and

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■■ Staff and volunteers at the Cleveland VAMC’s Wade Park Campus gather to show off their

red attire and their support for women’s heart health on National Wear Red Day, part of the American Heart Association’s “Go Red for Women” campaign. The VA coordinates events focused on women’s heart health every February in support of the campaign. men veterans. The document also notes that while the largest group of women veterans is those aged 45 to 64, who will require cardiovascular care as they continue to age, the influx of younger women veterans necessitates a focus on prevention of cardiovascular disease risk factors. Additionally, through the use of data from the VA cardiac catheterization laboratory clinical data registry, there have been several important research publications looking at insights into cardiovascular disease in women veterans. One recent publication from 20152 investigated 3,181 women veterans who underwent cardiac catheterization between Oct. 1, 2007, and Sept. 30, 2012. These women veterans had fewer classic risk factors for coronary artery disease (CAD) than men, but higher rates of obesity, depression, and post-traumatic stress disorder, and lower rates of obstructive CAD on angiography than men. These findings suggest that the clinical presentations prompting referral of women veterans for catheterization is not as likely to be due to obstructive CAD as it is in men. The VA looks to further research studies to help discriminate these gender differences in more detail and to develop effective treatments. 1 Whitehead AM, Davis MB, Duvernoy C, Safdar B, Nkonde-Price C, Iqbal S, Balasubramanian V, Frayne SM, Friedman SA, Hayes PM, Haskell SG. “State of Cardiovascular Health in Women Veterans. Volume 1: VA Outpatient Diagnoses and Procedures in FY 10.” Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs, October 2013. 2 Davis MB, Maddox TM, Langner P, Plomondon ME, Rumsfeld JS, Duvernoy CS. “Characteristics and outcomes of women veterans undergoing cardiac catheterization in the Veterans Affairs Healthcare System: Insights from the VA CART Program.” Circulation: Cardiovascular Quality and Outcomes 2015;8:S39-S47.

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

IVF FOR WOUNDED VETERANS

n AS WITH ALL WARS, the effects of recent conflicts on the nation’s veterans have taken their toll in many ways. One of the consequences of the widespread use of improvised explosive devices (IEDs) and the traumatic injuries they cause can be infertility. As noted in the Federal Register, “The Joint Theater Trauma Registry (JTTR) reflects the most common single cause of battle injuries is explosive devices (36.3%). Such trauma frequently results in genitourinary injury. … This increasingly common trauma can have catastrophic reproductive results.” While the medical benefits package for veterans has included numerous diagnostic and treatment services for 76

infertility, the Department of Veterans Affairs (VA) has been prohibited since the late 1990s from including among those benefits in vitro fertilization (IVF), a common, medically accepted procedure involving manual fertilization of eggs by sperm in a lab, with a resulting embryo being implanted into the uterus. But now, because of the yearslong efforts of lawmakers, advocacy groups, and veterans and their families, thousands of wounded veterans do have access to that additional means to start or expand their families. Specifically, an interim final rule authorizes the VA to provide IVF treatment to veterans with a service-connected

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U.S. NAVY PHOTO BY JACOB SIPPEL, NAVAL HOSPITAL JACKSONVILLE

By Gail Gourley

DR. ELENA KONTOGIANNI VIA WIKIMEDIA COMMONS

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

disability that results in the inability of the veteran to procreate without the use of fertility treatment. The rule also allows the VA to offer fertility counseling and treatment using assisted reproductive technologies (ART), including IVF, to a spouse of a veteran whose service-connected disability results in infertility. In both cases, the new rule marks the first approval for the treatments, and offers these veterans and families another alternative and further hope in fulfilling their desire to have children. These changes became effective in January as a result of legislation – the Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act – passed by Congress last September. Because of the law, explained Patricia Hayes, Ph.D., chief consultant for the Women Veterans Health Strategic Health Care Group in the VA Office of Patient Care Services, “VA drafted this interim final rule and published it in the Federal Register on Jan. 19, adding this new section to the VA law in the Code of Federal Regulations.” While advocates praised the law’s passage, Hayes pointed out that there is an end date to the rule. “It was passed under an appropriations law, and that law expires at the end of September 2018,” she said. “We are dependent on Congress to consider whether to renew this benefit by passing additional legislation.” Sen. Patty Murray, D-Wash., has been one of the staunchest promoters of ending the ban on covering IVF in the VA, and her amendment to the bill during a committee markup is what now allows it. But because the bill does not permanently repeal the IVF ban, she has expressed her determination to push for its full repeal. In a written response to Veterans Affairs & Military Medicine Outlook, Murray asserted, “As a nation, we promise our veterans we will take care of them after their service is over, no matter what. Yet for more than 20 years, because of politicians’ personal beliefs, the VA has been unable to help wounded veterans and their spouses fulfill the dream of having a family. I think this is wrong, which is why I have fought relentlessly for legislation that ensures fertility services for veterans who were injured while defending our country. “But our work is not over,” Murray continued. “I will keep working to repeal VA’s outdated ban once and for all. This is the least our country can do for the men and women who sacrificed so much to serve our country.” CONTINUITY OF CARE

While the VA did not cover IVF until recently, the Department of Defense (DOD) has provided IVF treatment to eligible service members on active duty. But when veterans left service, they were no longer eligible for IVF under the VA. The interim final rule notes that “most of the ART evaluation and treatment modalities offered by VA are consistent

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■■ ABOVE: A human embryo. OPPOSITE: Hospitalman Juliana Dejesus

conducts a newborn screening in Naval Hospital Jacksonville’s maternal infant unit. In vitro fertilization (IVF), a procedure that involves manual fertilization of eggs by sperm in a lab and the subsequent implantation of a resulting embryo into the uterus, is a medical benefit offered by the DOD but long denied to veterans. However, IVF can now be provided by the Department of Veterans Affairs to veterans with service-connected disabilities that affect their ability to procreate.

with DoD policy guidance. The exception is IVF. DoD offers IVF to servicemembers who have sustained serious or severe illness/injury while on active duty that led to the loss of their natural procreative ability, while IVF is excluded from VA’s medical benefits package …” With these changes, the interim final rule states, “This rulemaking will ensure that covered veterans leaving service at this time, and their spouses, will experience continuity of care when transferring from health care provided by DoD to that provided by VA, with no difference in the level or types of available ART.” Hayes elaborated on the importance of the ability to transfer care from one entity to the other. “One of the things we recognize is that when someone is seriously wounded in terrible IED injuries and blasts, they have a period of time that they may be discharged from active duty, but they may not be fully healed and back to a situation in which they’re thinking about activity or family life or having children,” she said. “They’re getting their lives back together. Many of them have been out of active duty for some time. They were eligible for [IVF] while they were on active duty, and so for us, it’s really changed things to be able to now say to those veterans, ‘OK, you took some time [to recuperate], but VA can now offer you this service.’” 77

■■ Sen. Patty Murray, D-Wash., met with families of wounded

veterans a month before the Senate approved a bill that would eventually become the Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response Preparedness Act. The act, which passed Congress in September 2016, includes IVF funding.

IVF AND OTHER FERTILITY TREATMENTS

While the Code of Federal Regulations explicitly excluded IVF from the VA medical benefits package until earlier this year, Hayes said, “I think some people don’t recognize that VA for quite some time has done infertility evaluations and treatment, including things like ovarian stimulation for certain conditions, sperm retrieval, freezing of sperm for veterans who have malignant conditions and cancer treatment, freezing of the ovum, and artificial insemination. We were able to do many things; we just weren’t allowed to do the in vitro fertilization part of infertility treatment.” Other treatments VA has long provided include infertility counseling, laboratory blood testing, semen analysis, genetic counseling and testing, ultrasound, reversal of tubal ligation and vasectomy, hormonal therapies, surgical correction of structural pathology, and others. These treatments have been for veterans only, and Hayes said that part of the former difficulty regarding infertility treatment was that VA is only allowed to treat veterans, not families or spouses. “When you get into things like fertility, obviously treatment in the past has been difficult because 78

fertility is really a diagnosis of a couple trying to become parents, become pregnant,” she said. A key difference now, regarding infertility treatment only, is that “the new law and the new regulation allow us to treat a specific group of veterans and their legal spouses.” Hayes explained how a veteran would begin the process. “If they haven’t been evaluated for infertility, then we would start with that,” she said. “Men would go to a urologist in the VA, or in the community if distance is an issue, and a woman would go to a gynecologist. If they’ve already been in a process where they’ve been evaluated somewhere else, it’s already been determined what they need, then they could bring their records in to the VA and be referred to a reproductive medicine clinic to continue their treatment.” If IVF is indicated, Hayes reiterated that the process starts with the veteran, who, to be eligible, must be legally married and have a service-related condition that results in the inability to have children without fertility treatment. The interim final rule specifies what this means: “for a male veteran, a service-connected injury or illness that prevents the successful delivery of sperm to an egg; and, for a female veteran with ovarian function and a patent uterine cavity, a service-connected injury or illness that prevents the egg from being successfully fertilized by a sperm.” These conditions could result from not only genitourinary injury in men and women, but also other combat trauma such as brain or spinal cord injury. Hayes said, “More often for women it’s an illness, a PID [pelvic inflammatory disease], a fallopian tube obstruction – something that occurred while they were in the military, it is documented, and they are rated by the VA as having a service-connected disability.”

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WOUNDED WARRIOR PROJECT PHOTO

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Without specifying an exact number of veterans who have begun the process under the new law, Hayes said, “We projected that the total group was going to be about 450 a year, based on the number of people we know have these rated conditions,” with a total pool of about 4,500 veterans. Hayes added that instead of having a list of IVF-eligible conditions, “We go on a case-by-case basis to determine what the infertility situation is, what’s causing the infertility, and then look to their service-connected graded conditions to see if there’s something that relates to their infertility.” Describing where IVF services are delivered, Hayes said, “We provide a lot of fertility evaluation, however, reproductive endocrinology and actual IVF is not provided inside of VA facilities. We don’t have the technology for this, for what is actually a relatively small population. We are using contracts with outside providers in the veterans’ community area.” In the IVF process, “they can go through a number of cycles to try to be effective. If it’s not effective the first time, we can have up to three completed cycles.” Hayes explained. One IVF cycle takes about two weeks. “Hopefully, [the process] goes on to a successful pregnancy. What we know from the science is that IVF can be about 80 percent successful by the time you’ve gone through three attempts, three cycles,” she said. COMMUNITY RESOURCES

“We want veterans to start with us first, and see what they’re eligible for and how we might be able to help them out,” Hayes said. But, while not endorsing any particular organization, she identified other resources for those who don’t qualify for this VA benefit; for example, if they don’t have a service-connected injury, or they’re not legally married. A representative sample of these resources for infertility services include local and national veterans’ organizations like the Wounded Warrior Project; financial assistance programs for fertility products through Ferring Pharmaceuticals and EMD Serono Inc.; discounted IVF services through members of the American Society for Reproductive Medicine; and the infertility advocacy group RESOLVE: The National Infertility Association. Another example of organization support is the Bob Woodruff Foundation (BWF), which established an IVF fund offering financial assistance to help veterans cover unreimbursed costs of IVF treatments. Barbara Lau, IVF fund administrator, said the organization’s commitment to this endeavor strengthened following a 2014 BWF-hosted conference on intimacy after serious injury. “It was a great big shock, I think to many people, to discover that, at the time, VA was prohibited by law from providing IVF services,” she said. “So we did two things. We decided to put money toward this and offer eligible applicants $5,000 toward unreimbursed

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■■ For more information about infertility services including IVF, veterans are urged to contact their local VA facility. Alternately, they can call the Women Veterans Call Center at 1-855-VA-WOMEN or 1-855-829-6636. This is the correct resource for men and women to obtain information or a referral to an appropriate VA contact.

IVF treatment costs. It’s not going to cover everything by a long shot, but for many of them, it’s a big help,” Lau said. She continued, “Simultaneously with that, we joined hands with 14 other organizations. We didn’t lobby because we can’t, but we advocated with members of Congress that they really needed to support the bill that was coming up.” Lau said the group of 15 organizations “advocated very strongly that if these men and women can be supported [with IVF] while they are on active duty, let us enable them to be supported once they are medically retired and veterans. And lo and behold, it passed.” Emphasizing the commitment of the BWF, Lau said, “If you look at our tagline underneath our logo, it says, ‘Investing in the next chapter for our veterans.’ What could be more lifeaffirming, more normal, than to want to have children?” Hayes reinforced that message. “When you think about these very seriously injured veterans who just want to be able to have a family, there is more of a feeling that this [ruling] allows us to really help them complete their quality of life and their family life,” she said. “I think that this is part of the sense of what a tremendous sacrifice these individuals have given for the country,” Hayes continued. “I talk with them, and it’s always touching to hear about the horrendous things they’ve been through and how far they’ve come, and their intense desire to have a full life; and that life includes having children. “For me, it just fulfills that sense that we owe them for everything they’ve done,” concluded Hayes. “If these folks aren’t deserving, I don’t know who is, when we think about the ultimate sacrifices that veterans give to keep us safe. I think that’s the message about who these folks are, and how important it is to them for us to be able to help them out.” 79

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

INTERVIEW

LINDA McCONNELL Chief Nursing Officer, VA Office of Nursing Services By Rhonda Carpenter

■■ Linda McConnell, Chief Nursing Officer, VA Office of Nursing

Services.

organizations, including the American Organization of Nurse Executives, American Nurses Association, American College of Healthcare Executives, and Sigma Theta Tau International Honor Society of Nursing. She is currently pursuing her doctorate in nursing practice.

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VA PHOTO

n As the Veterans Health Administration (VHA) Chief Nursing Officer (CNO), Linda McConnell provides executive leadership and strategic direction for the Office of Nursing Services (ONS). She advises the under secretary for health on nursing issues that impact veteran care for the more than 98,000 Department of Veterans Affairs (VA) nursing personnel nationwide. She collaborates with VHA leaders to plan for current and emerging health care needs of the nation’s veterans. Prior to her current position, McConnell served as the associate director for patient care and nursing services and chief nurse executive (CNE) for a large level 1c VA health care system, serving approximately 55,000 veterans. She was responsible for planning, directing, and managing nursing service, education and staff development service, sterile processing service, social work service, and chaplain service, with more than 800 direct-line employees and a budget surpassing $70 million. McConnell previously provided sound leadership for patient care improvements serving as the associate director for nursing services for a large level 1a complexity VA health care system and tertiary care referral center, serving approximately 42,000 veterans. She has a broad background providing leadership for various patient care programs areas such as medical, surgical, intensive care, mental health, spinal cord injury, polytrauma, primary care, outpatient specialty care, and extended-care programs. McConnell has successfully completed a number of highly regarded leadership development programs. She completed the Executive Career Field Development Program, Leadership VA, and the Federal Executive Institute Nurse Executive Program. Additionally, McConnell is board certified by the American Nurses Credentialing Center as an advanced nurse executive and certified as a Fellow of the American College of Healthcare Executives. She is a member of numerous professional

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Veterans Affairs & Military Medicine Outlook: What do you see as the biggest challenge facing the Office of Nursing Services? Linda McConnell: The biggest challenge facing the Office of Nursing Services is ensuring VHA has a highly competent nursing workforce, well prepared to meet the complex, specialized, and dynamic care needs of veterans during a time of transformation in the largest integrated health care system in the country. Issues are somewhat unique in VHA, because of the distinct medical, mental, and social needs of the veteran population that requires coordination of care and services for their complex issues. Additionally, the focus on health promotion and disease prevention in VHA signals a requirement for nurses to advance the health and wellness of our veteran population through our unique skills. To enable transformation in care delivery, reduce cost, and improve quality and population health, nurses must practice to the full extent of their licensure, education, and training. In the Office of Nursing Services, we are focusing on effective workforce planning with nursing leaders, driving policy changes for improved processes, advancing nursing practice, and improving infrastructure to support decision-making. What are some of the strategies used to attract new nurses at the VHA? There are a number of strategies used in VHA to attract new nurses. To be a successful organization, we must hire the best talent, which means hiring the right nurse, in the right job, so they will be an engaged and productive employee. This year we published a booklet entitled, “20 Reasons Nurses Love Working for the Veterans Health Administration,” to disseminate information about our exceptional nurses and the rewarding work that they do. The professional satisfaction gained by serving heroes of our nation is important in the recruitment of other nurses by our very own nursing staff. When nurses feel positive about their experience and work in an environment that is supportive of nurses, they are more likely to convince others to join them. Therefore in VHA, we focus many of our efforts on nurse engagement and RN satisfaction. As a valued and integral member of the team, VA nurses focus on teamwork and collaboration with other colleagues. I believe that leaders need to invest in nurses and foster the kind of work environment that will enable them to retain their experienced staff. VHA offers attractive benefits to recruit nurses. For instance, we offer time off for work-life balance that includes 26 days of annual leave per year, 13 days of sick leave per year, 10 federal holidays per year, and a leave accrual option. In addition, we offer various f lexible work shifts and part-time work options to attract nurses. One particular benefit is our educational debt reduction program, which allows for assistance in repayment of student loans for hard-to-fill positions. We also fully

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support our military employees with military leave and boast about our unparalleled retirement system. At the national level, the Office of Nursing Services staff works closely with the Office of Workforce Management to design and develop processes that support nursing recruitment and retention. When other health care organizations increase wages, VHA responds to ensure we retain current staff. As such, we concentrate on refining our hiring processes and establishing competitive pay. ONS also supports the expansion of the VHA Travel Nurse Corps to meet urgent needs and address areas of nursing shortages.

■■ “… the focus on health promotion and disease prevention in VHA signals a requirement for nurses to advance the health and wellness of our veteran population through our unique skills.” Looking toward the future, we are mindful of the imperative to invest in technology in order to meet veteran care needs and to draw the best nurses to our system of care. Research shows reductions in errors and improved care and delivery with the implementation of information technology. The future generation of nurses expects a tech-savvy work environment. Therefore, nursing leaders in VHA support the role of nurses in designing, developing, and implementing health information technology, which is necessary so that systems support the work of the nurse. VHA is a leader in telehealth, and nurses have the opportunity to participate in programs, such as the Home Telehealth program, which has been shown to positively impact the health outcomes of veterans. Further, continued support for the role of nursing in the implementation of the new electronic health record in VHA is essential to capture data about nursing and patient outcomes that enable decisions about care. To follow that, are there continuing educational programs in place for nurses to advance? Is the RN Transition-to-Practice initiative an example? In VHA, we do offer support for continued development of the individual nurse. We accomplish this in various ways. First, we offer many continuing education programs for nurses through various modalities, such as face-to-face training and virtual training. For example, the ongoing education of nurses occurs in local facilities that includes simulation-based learning and the use of high-tech equipment. 81

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■■ The booklet “20 Reasons Nurses Love Working for the Veterans

Health Administration,” published earlier this year, shares information about the rewarding work nurses do for veterans to attract new nurses to the VHA workforce.

shortages of experienced nurses in some geographic areas. ONS is currently forecasting a need to increase the number of nurses in nurse residency programs to meet future nursing resource needs.

REASONS

VA IMAGE

Nurses Love Working for the Veterans Health Administration

VHA also offers nursing scholarships and tuition reimbursement for advancing the formal education of nurses. Support is offered for RNs seeking baccalaureate and advanced nursing degrees, to include funding in priority areas that support full-time enrollment in school. We seek nurses with a bachelor’s or advanced degree in nursing, who demonstrate empathy, responsibility, and motivation to continuously learn how to improve their practice. Our goal in VHA is to achieve 80 percent of our nursing workforce with a bachelor’s degree or higher. For our more experienced nursing staff, there are other VHA leadership programs available to promote learning and professional development. We are very proud of our nurse residency programs that support the transition of new graduate nurses to the clinical practice environment in VHA. VHA supports an Office of Academic Affiliations RN Residency Program and an RN Transition-to-Practice [TTP] program. These programs ensure competency in the areas of clinical nursing and quality of care, organizational skills, evidence-based practice [EBP], and communications skills that are necessary for the complex health care environment. The RN TTP program was developed to meet a particular need in VHA for expanded hires of new graduates. VHA data ref lects high retention rates of these new graduate nurses, which helps address critical

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Across the VA system, which specialized nursing role is needed most? Considering the value VHA places on health promotion, disease prevention, population health management, and holistic care, to include care in the community, the role of nurse care coordinator becomes increasingly important. VHA optimizes the contribution of the nurse in a team-based care delivery model to improve both health outcomes and the well-being of veterans. Nurses anticipate and meet the unique needs of veterans, including our most vulnerable populations. They provide effective communication for engagement of veterans and their families in their care delivery. Nurses are committed to veteran-centered care delivery that exceeds care in the private sector related to clinical outcomes and care experience. Also, nurses meet the new challenges continually faced in this rapidly changing health care environment by working to the highest level of their education and experience. Care coordination and smooth transitions across care settings are foundational to our success as a health care organization. Nurses contribute significantly towards the goal of maximizing the utilization of lower-cost approaches toward care delivery, and nurses enable efficient management of patients in our primary care clinics. VHA adopted the RN Care Manager role on the Patient Aligned Care Team in the primary care setting, and now the Office of Nursing Services is moving towards expanding the role and responsibilities of the nurse to enhance the productivity of providers and address the whole health of the patient. How important is EBP in VHA and how does it affect patient care? Evidence-based practice is critical to achieve the best quality outcomes expected for veterans. Many quality indicators are specifically sensitive to nurse interventions. Implementation of new evidence-based practices will propel changes that we are working toward in VHA. We are raising our expectations! With emphasis on innovation, nursing is keeping pace with advanced technology and assimilating new knowledge that defines best practices. However, creating the practice environment 83

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necessary for success requires accountability among our nursing leaders to lead staff in implementing promising new practices. Since evidence-based practice requires specific skills of the nurse, the Office of Nursing Services provides education and consultation in field facilities to encourage and support the implementation of evidence-based practice. In addition, we support the capability for diffusion of best practices across the system by nurse participation in the VA Diffusion Hub [a best practices tool]. This year, VA granted full practice authority to the advanced practice registered nurse role, certified nurse practitioner, clinical nurse specialist, and certified nurse midwife. What does this mean and how does this affect patient care? In VA, the implementation of full practice authority [FPA] permits three roles – the certified nurse practitioner, clinical nurse specialist, and certified nurse midwife – to practice to the full extent of their education, training, and certification, regardless of individual state restrictions, except for applicable state restrictions on the authority to prescribe and administer controlled substances. This is applicable when advanced practice registered nurses [APRNs] in these roles perform work within the scope of their VA employment. APRNs provide a valuable resource to effect positive change by providing additional access to care, particularly in underserved areas. This regulation change facilitates efficient and streamlined care processes, making best use of the physician and APRN time for patient care. Under FPA, the APRN practices independently as a provider of care performing interventions such as physical assessments, diagnosis, testing, and prescribing with responsibility for the quality outcomes for each individual they treat. Welldefined clinical privileges delineate the APRN’s specific role at each VA facility. Research supports the implementation of FPA, showing quality outcomes and the necessity for APRNs to fill the need for additional providers. Veterans benefit from the collegial, interdisciplinary communication and team-based care they receive. Tell us about the VA’s academic partnerships. Who are the partners and what are the benefits of these partnerships? How do they contribute to veterans’ health care? VA’s partnerships with nursing schools across the nation reflect a highly successful model of academic affiliations in nursing, developed to meet current and future needs of student nurses and VA graduate nurses. These partnerships are designed to expand nurse professional development, increase nursing student

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enrollment, and expand opportunities for nursing practice innovation and scientific inquiry. Additionally, these partnerships enhance recruitment and retention of VA nurses through various program enhancements accomplished through the partnerships. These partnerships are especially important for training student nurses about veteran care because these nurses will care for the nation’s veterans who receive some or all of their health care in the private sector.

■■ “VA nurses are caring, compassionate professionals who advocate for every veteran and communicate with them throughout their experience in our health care system. VA nurses provide unparalleled care coordination, assuring each veteran receives the services they need.”

If you were in a room with newly enrolled veteran patients, what would you want them to know about their VHA nurses? VA nurses are caring, compassionate professionals who advocate for every veteran and communicate with them throughout their experience in our health care system. VA nurses provide unparalleled care coordination, assuring each veteran receives the services they need. We accomplish this through communication with other health team members. The VA nurse wants to know each veteran’s individual goals to assist them to achieve health and well-being. VA nurses also provide education to assist them to reach their goals. It is the nurse who will be at their side if they require hospitalization. Since nurses use evidencebased methods to enhance the veteran experience, veterans will appreciate our caring and empathetic interactions. VA supports innovative clinical practice in order to meet veterans’ needs and nurses actively pursue new practices to provide the best care. VA is a leader in patient safety and our nurses receive support for processes and equipment that enhances veteran safety. Nurses bring to veterans dignity, respect, understanding, and clinical expertise to meet their expectations. As the most trusted profession, we are proud to say we are part of the care team and privileged to participate in health care services for veterans. 85

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TARGETING CANCER VA flexes its muscle – and leverages its many partnerships – to bring cutting-edge cancer care to a growing number of veterans.

n IN SPRING 2017, WHEN THEY LAUNCHED their yearslong study of lung cancer treatments, Drew Moghanaki, M.D., MPH, a radiation oncologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia, and Tomer Karas, M.D., FACS, a thoracic and cardiac surgeon at the Miami VA Healthcare System, were attempting something that had been tried before: comparing the effectiveness of radiotherapy to that of surgery, which has long been the standard treatment for early stage lung tumors. Previous comparison studies of surgery and radiation to treat lung cancer, Moghanaki said, have been historically difficult to complete. There have been insurmountable 86

challenges in recruiting and treating a large enough cohort of patients to truly understand if there are differences between these treatments. Five such trials have been attempted, said Moghanaki, but all were closed because they couldn’t recruit enough participants. “It’s a difficult choice to make,” he said, “to go on a trial that’s going to flip a coin to decide your treatment.” But Moghanaki and Karas have several advantages over their predecessors: First, advances in radiation techniques, over the past 20 years, have led to the discovery of a new form of treatment, known as stereotactic radiotherapy, that may be just as good as or even better than surgery for controlling lung cancer. But, as Moghanaki cautions, “While

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By Craig Collins

U.S. AIR FORCE PHOTO/STAFF SGT. LILANA MORENO

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there’s reason for enthusiasm that most patients can avoid surgery, there still isn’t any convincing evidence that this is the case.” A second advantage is the VA’s track record in completing difficult randomized trials. “Our veterans have always been willing to serve our nation,” said Moghanaki, “and the history of successfully completed clinical trials in the VA is a testament to their willingness to help others with similar health problems.” The study being conducted by Moghanaki and Karas, known as the VALOR trial, benefits from the capacity of the Veterans Health Administration (VHA) – the largest integrated health care system in the United States – and the VA Cooperative Studies Program, which has been coordinating large, multicenter clinical trials since the 1970s. One such study, the CONFIRM trial, is the largest clinical trial ever sponsored by the VA, evaluating the two most common types of colorectal cancer screening among 50,000 veterans. Large multisite studies such as the VALOR and CONFIRM trials, Moghanaki said, allow the VA to directly address some of the most important clinical questions facing practitioners. He sees his own study – which he and Karas hope will include 670 veterans with lung cancer – as having the same potential to change how doctors treat patients with lung cancer as a 1991 VA larynx trial that compared radiation plus chemotherapy to surgery. “Before that trial,” said Moghanaki, “if

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■■ ABOVE: Lt. Col. (Dr.) B. Zane Atkins, center, 60th Surgical

Operations Squadron chief of cardiothoracic surgery, performs videoassisted thoracoscopic surgery on a patient with lung cancer at David Grant USAF Medical Center. OPPOSITE: Radiation therapist Dramane Niambele (left) and Deborah Citrin, M.D., Radiation Oncology Branch, National Cancer Institute, prepare a patient for radiation therapy in a TrueBeam™ unit. A recently launched study by VA doctors is comparing the effectiveness of radiotherapy to that of surgery for early stage lung cancer.

you had laryngeal cancer, it was going to get cut out, and you weren’t going to swallow or talk the same ever again.” The larynx trial found no difference in survival between the two treatment methods. “So now when patients have a laryngeal cancer, we start with upfront radiation and chemotherapy, and two-thirds of the time a patient will sustain the ability to swallow and speak, and have the same cure rate as if they’d had up-front surgery.” The VALOR trial is aimed at a similar question, said Moghanaki: “Can we just start with radiation first, to avoid anesthesia and the risk of complications for surgery? Surgery could still be a backup option for the minority for whom radiation might not work. That’s kind of why this study stands out so much. There are a lot of eyes on it.” 87

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■■ A sample containing genetic material from the Million Veteran

VA PHOTO

INCREASING VETERAN ACCESS TO NEW TREATMENTS

It isn’t the VHA’s size alone that enables it to increase the number of veterans who receive innovative cancer treatments, Moghanaki said – it’s also the way its professionals both work together and collaborate with others in the wider world. Lung cancer treatment requires a multidisciplinary approach, and in ordinary health care settings, patients are often shuttled from one specialist to another. “Here everything is under one roof,” said Moghanaki, “and it makes it more likely for people to work together. “We also don’t have to deal with complicated issues involving insurance companies. In this trial, you need surgeons and radiation oncologists, and a pulmonologist, most importantly, to work together to talk to vets and help them realize: You actually have an option. You don’t have to have surgery. You can go into this trial instead.” Moghanaki also serves as the research chair for a professional society of VA physicians – the Association of VA Hematology/Oncology, or AVAHO, a nonprofit organization, not affiliated with the VA, that provides a forum for interaction for the department’s hematology/oncology professionals. “The research group is working really hard to expand the cancer trials in the VA, in addition to what VA already does.” Vast as the VHA is, he said, “it doesn’t have

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Program (MVP) is identified by barcode. The MVP data set, which includes the genetic, military service, lifestyle, and health information of more than 500,000 veterans, can be analyzed to identify potential targets for cancer detection and intervention.

the bandwidth to solve every health problem. People often look to the National Cancer Institute [NCI] as a better route to help recruit participants in cancer trials. There’s a lot of missed opportunities right here in the VA to get important clinical trials completed.” NCI, which launched its $1.8 billion Cancer Moonshot initiative last year, is an important partner in the VA’s efforts to expand the knowledge base around cancer and make clinical research trials more accessible to veterans. The VA has partnered with the Department of Energy and IBM to apply some of the world’s most powerful computing assets to the growing data set compiled by the VA’s Million Veteran Program, which has now collected information about the genetics, military service, lifestyle, and health of more than 500,000 veteran volunteers. In collaboration with NCI, the Uniformed Services University of the Health Sciences (USU), and Walter Reed National Military Medical Center, the VA will apply state-of-the-art methods in proteogenomics to analyze data 89

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from thousands of patients. Based on these molecular analyses of genetics and protein expression, researchers will identify potential targets for cancer detection and intervention. Because cancer is, fundamentally, a failure to regulate cell growth, caused by genetic mutation or altered genetic expression, it’s a particularly promising target for study in the emerging field of precision medicine, an approach to diagnosis and treatment that takes into account individual differences in genes, environments, and lifestyles. The ability to sequence the genes of individual patients offers the opportunity to develop drugs that target specific mutations, and NCI has launched a nationwide clinical trial, the MATCH (Molecular Analysis for Therapy Choice) trial, conducted at nearly 1,100 hospitals and clinics, to evaluate the responses of certain tumors to existing drugs and to experimental drugs that show promise for treatment. Over the last couple of decades, for a variety of reasons, it has become more difficult for veterans enrolled in VHA care to participate in trials conducted outside the VHA and affiliated university settings, but the VA is working with NCI to enable more veterans to enroll in such trials, including the MATCH trial and the Lung-MAP trial, a precision medicine trial testing five new drugs for squamous cell lung cancer at 730 treatment centers throughout the United States. One of the largest research consortiums in the institute’s National Clinical Trials Network, SWOG (formerly the Southwest Oncology Group) administers the VA Integration Support Program, providing grant funding to VA medical centers through its charity arm, the Hope Foundation, to help connect veterans to clinical trials. SWOG is a major component of cancer research infrastructure, with 12,000 members in 47 states and six foreign countries. The advent of precision medicine, coupled with the capacity of the VHA to conduct largescale clinical trials using an integrated health system, genomic database, and electronic medical record, has spawned other partnerships as well. Last year, for example, the VA and the Prostate Cancer Foundation (PCF) announced a $50 million precision oncology initiative to expand veteran access to prostate cancer clinical research and speed the development of new treatment options and cures. An estimated 12,000 veterans are diagnosed with prostate

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■■ The VA is working with the National Cancer Institute to enable more veterans to

enroll in clinical trials outside of the Veterans Health Administration, including some precision medicine trials.

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cancer each year, making it the most frequently diagnosed cancer among veterans. FROM LABS TO CLINICS

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The PCF partnership is multifaceted: It’s aimed at increasing the number of VHA investigators applying to the foundation for funding, the number of VHA facilities involved in precision medicine/prostate cancer clinical trials, the number of minority participants enrolled in PCF studies, and the number of early career scientists working on prostate cancer research. But according to Michael Kelley, M.D., VA’s national program director for oncology and a professor at the Duke University School of Medicine, the initiative shares one overarching objective with VA’s other cancer partnerships: to expand veteran access to cuttingedge treatments. “The core of the PCF partnership is to bring therapies that are not yet approved for use by the FDA [Food and Drug Administration] to patients in the VA system,” he said, “so that when we identify that they have a particular gene alteration that might be targeted by a drug that isn’t yet approved, they might be able to access that treatment. The pharmaceutical partners are also a big part of this, because they are able to help us bring new drugs to clinical trials, and work with us in terms of delivering care to veterans that need new types of therapies.” Several other VA partnerships, to study the effectiveness of precision oncology treatments for other types of cancer, such as breast cancer, leukemia, and lymphoma, are in the developmental stages. In 2016, Kelley and Dr. Neil Spector, VA’s national director of precision oncology, established the VA’s Precision Oncology Program (POP), which makes genetic testing available to VA cancer patients for whom testing may help determine either a course of treatment or a prognosis. Originally launched within the New England Healthcare System, the program has now been expanded nationwide. Through its various activities, the POP system encourages access to modern oncology genomic practice in the VA, improves quality outcomes across the VA network of clinical centers, and works to remove disparities of access to cuttingedge therapies. The question of access is particularly acute for the VA, Kelley said. “We know VA serves a population which is more highly rural than the national population. About 14 percent of Americans live in rural areas, whereas about 33 percent of those enrolled in the VA are rural residents. ... When you look at the cutting-edge therapies that are coming out in academic medical centers, these are often focused on individuals who live in more urban areas. Rural Americans and rural veterans have not had equal access.” Given the vast

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MARTHA HOELZER

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amounts of data involved in precision oncology diagnosis and treatment, it can be challenging for clinicians – urban or rural – to deliver on its promise. According to the VA, however, about 35 percent of the veterans who receive precision oncology services live in rural areas – which means these rural residents are receiving precision oncology care in roughly the same proportion as their urban counterparts. “VA is able to deliver the latest paradigm in oncology care throughout our system,” Kelley said. “We’ve done that with our various partnerships, and we’re increasing the therapeutic options in several ways.” VA’s partnership with IBM, for example, will allow for VA pathologists and clinicians to sequence DNA for cancer patients, and then feed data to Watson, IBM’s supercomputer. Watson’s technology platform will enable comparison of a patient’s information to existing medical literature to identify likely cancer-causing mutations and possible treatment options – tasks that would otherwise be incredibly time consuming and beyond the resources of many community clinicians. Of course, the purpose of the Precision Oncology Program itself is to extend guidance to clinicians and pathologists throughout the system who are not fully up to speed on a new and rapidly evolving field of medicine. While VA’s current precision oncology efforts emphasize matching veterans to clinical trials of existing and experimental therapies, Kelley said the POP also provides an opportunity for big-picture studies of how to improve precision oncology implementation throughout the VHA. In many

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■■ VA oncologists Michael Kelley (left) and Neil Spector, who

established the VA’s Precision Oncology Program, review a Watson for Genomics DNA analysis report. The VA and IBM have launched a public-private partnership to help doctors expand and scale access to precision medicine over the next two years for 10,000 American veterans with cancer.

ways, the system already has an impressive record, he said. “We’re above 80 percent screening for colorectal cancer, and have been since 2009. That’s 10 years ahead of the national goal to get to that level. How did we do that? It’s been through stuff that can be kind of boring if you’re an oncologist: implementation science. Operational engineering. It’s making sure the car that rolls off the production line doesn’t have any flaws in it. So how do you do that in a patient care setting, where there are so many more variables?” VA researchers are already discussing ways of evaluating how the existing POP system might be expanded to allow even greater numbers of veterans with cancer to receive treatments matched to their specific proteogenomic information. “Precision oncology was designed to be a platform to handle research built on it,” Kelley said. “And it’s happening already. We’re very interested in partnering with all types of entities – commercial, nonprofit, and government partners – to leverage all the opportunities available and improve cancer care for veterans.”

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DIABETES: A PERSONAL APPROACH The VA and DOD’s new guidelines for managing diabetes ramp up a focus on the individual patient. By Craig Collins

n WHILE THE POPULATION OF U.S. VETERANS is a fairly representative slice of the American population, there are some differences, particularly among veterans enrolled to receive health care in the Veterans Health Administration (VHA). One of the most conspicuous differences is in the prevalence of diabetes, a chronic disease in which the body cannot produce or properly use the metabolic hormone insulin, resulting in elevated blood glucose. • According to the U.S. Centers for Disease Control and Prevention, an estimated 30.2 million Americans, 9.4 percent of the population, have diabetes. About 9.9 million, or 40 percent, of persons with diabetes are 65 or older. • Of the more than 5.6 million veterans who received care in the VHA through mid-2017, by contrast, more than 1.5 million – about 27 percent – have diabetes. Among these veterans, about 70 percent are aged 65 or older. Older adults with diabetes often have significant coexisting conditions or complications, a lack of social support, or food insecurity, circumstances that increase the likelihood of hypoglycemic reactions – episodes of low blood sugar or “insulin shock.” While many Americans with diabetes – a little over half – are estimated to be otherwise healthy, this number is somewhat lower among veterans; about 40 to 45 percent of veterans with diabetes have no serious coexisting disease. The most common form of the disease, type 2 diabetes mellitus, is the leading cause of blindness, end-stage kidney disease, and amputation for VA patients, and often leads to stroke, nerve damage, and contributes to cardiovascular disease – the leading cause of death among all persons with diabetes. Since 2000, to accommodate the particular needs of patients in the VHA and the Military Health System, the 94

Department of Affairs (VA) and the Department of Defense (DOD) have periodically convened expert panels to review published literature and develop guidelines for diabetes care. The latest version of their “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” was published in spring 2017, and was developed in collaboration with ECRI Institute, a nonprofit dedicated to applying scientific research findings to the improvement of patient care. The new guidelines include 25 recommendations for overall care, glycemic control, pharmacological treatment, inpatient care, and complications in treating type 2 diabetes. Most of the guidelines have either been revised or carried forward without review from previous versions. A few of these recommendations, while not strictly “new,” emphasize elements of diabetes care that are ripe for change in a health care system that’s becoming increasingly patient centered, including: • Individualized treatment targets for blood sugar levels. A diagnosis of diabetes is often based on what’s known as the A1c test, a two- or three-month average of glycated hemoglobin – the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. An A1c result of 6.5 percent or higher on two separate tests indicates diabetes. The practice of blood glucose control has evolved slowly since Leonard Pogach, M.D., the VA’s former program director for diabetes and now its national director of medicine, began his VA career 36 years ago. After a generation of World War II veterans suffered through an era in which the benefit of blood glucose management wasn’t well established – “Many patients,” Pogach said, “had the major complications of blindness, dialysis, and amputations” – the VHA was

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PHOTO BY MARCY SANCHEZ

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one of the leading organizations in developing the first set of national measures to address the control of blood sugar. In 2003, the VA/DOD guidelines were the first diabetes guidelines to recommend that clinicians develop individual glucose targets that were based upon patient preferences and their individual benefits and risks – especially low blood sugar from insulin. Indeed, major professional society guidelines did not adopt this approach until about 10 years later. During that time period, a number of organizations aimed for what they called “optimal control” of blood glucose, an A1c target of 7 percent or lower for all patients. While the VHA never signed onto this one-size-fits-all standard, citing a lack of evidence supporting its universal benefit, it proved difficult to avoid, as VHA clinicians were often affiliated with other institutions, including university hospitals. The problem with aggressively medicating patients to a strict less than 7 percent standard, especially for the generally older veteran population, is that it can sometimes do more harm than good, explained Paul Conlin, M.D., chief of medical service at VA’s Boston Healthcare System and an associate professor of medicine at Harvard Medical School. “Anyone who is treated for diabetes,” he said, “runs the risk of their blood sugar being treated to a level below what we consider to be acceptable.” Low blood sugar, or hypoglycemia,

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■■ A sign asks patients with diabetes about their A1c levels at the

Internal Medicine Clinic at William Beaumont Army Medical Center, which provides primary care for active-duty soldiers and specialty care for referred beneficiaries, retirees, and veterans. The latest VA/ DOD “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” lists 25 recommendations for overall care, one of which is individualized treatment targets for blood sugar levels.

carries symptoms that range from mild – light-headedness, increased heart rate, headache – to severe: Hypoglycemia can cause a person to lose consciousness, which can be the proximate cause of accidents and falls. A 2014 study of patients using Medicare (the federal health insurance program for Americans aged 65 and older) found that there were 40 percent more emergency room visits for low blood sugar than for high blood sugar. “In older adults, hypoglycemia looms large as a potential adverse effect,” said Conlin. “And with any medication, there are unique and infrequent but occasional side effects that can occur. Any medication that carries risks, if it’s not providing benefit, should be re-evaluated. Risk and benefits should be counterbalanced in arriving at an individualized treatment.” In 2014, the VHA announced the Choosing Wisely Hypoglycemia Safety Initiative, which was based upon an 95

PHOTO BY STAFF SGT. DAVID WILLIAM MCLEAN, NCNG

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existing program developed by the VISN 12 (VA Great Lakes Health Care System). The program is aimed at reducing glycemic overtreatment, particularly among older patients with comorbidities that increase the risk of serious hypoglycemia. The current guidelines emphasize the importance of this risk/benefit calculus in setting A1c target ranges. • Race and ethnicity as factors in diagnosis and treatment. One of the problems associated with a fixed 7 percent A1c target is that, for whatever reason, studies of patients, both within and outside the VHA, reveal variations in baseline A1c values among different racial and ethnic groups. Among white and African-American patients who have the same value of one measure of blood sugar, for example, estimated average glucose (eAG), the A1c value for African-American patients tends to be about 0.4 percent higher than white patients. However, there is marked individual variation, and can occur among all races. “This has been mentioned in previous guidelines,” Conlin said, “but we’ve re-emphasized it.” It’s an important corollary to the emphasis on individualized A1c target ranges for both diagnosis and treatment: “Because race is a complex social construct,” said Pogach, “the guidelines don’t recommend different targets for different individuals based on race. But it is important to recognize that an A1c value can reflect different levels of blood sugar control in different individuals based upon their own biology. If we simply react to a single number that’s within a range, rather than looking at all the available information and asking patients about their preferences, it can lead to an unnecessary increase in medication when it’s not warranted.” • New nutrition-specific recommendations. Good nutrition is a key aspect of diabetes management, for both weight loss and the regulation of blood sugar, and it’s one of several lifestyle changes, including physical activity, quitting smoking, weight control, and limiting alcohol intake, that has long been a feature of the VA/DOD guidelines for diabetes care. Dietary recommendations tend to be controversial – and the latest version of the guidelines acknowledges that “the ideal distribution of the three main food components, carbohydrates, proteins, and fats, remains unclear.” Recent studies have brought some nutritional information into clearer focus, however, and led to the inclusion of two new nutrition-specific recommendations. First, the guidelines explicitly recommend – if it aligns with a patient’s values and preferences – the Mediterranean diet, which features an abundance of fruits and vegetables; lean protein sources such as fish and poultry; whole grains; legumes; and olive oil, which contains monounsaturated fats. Studies have shown the Mediterranean diet to have a benefit in reducing symptoms and the risk of cardiovascular disease. Among patients who don’t choose the Mediterranean diet, the guidelines recommend a reduction in carbohydrate intake. This involves both a lower overall carbohydrate intake and a focus on what’s known as the glycemic index. “If you

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■■ Sgt. Joshua Kirkpatrick of the 449th Theater Aviation Brigade,

North Carolina National Guard (NCNG), has Type 1 diabetes. Here, he tests his blood sugar following an event of the NCNG Best Warrior Competition on March 7, 2017, where he won NCO Warrior of the Year. Since 2000, the Department of Defense and the Department of Veterans Affairs have worked together to develop guidelines for diabetes care.

ate a tablespoon of table sugar,” explained Conlin, “your blood sugar would go up to a much greater extent than if you ate the same amount of sugar in the form of a piece of fruit, or maybe in the form of a complex carbohydrate like a grain or bran. It’s the same amount of carbohydrate, but in a different form, it’s going to cause your blood sugar to change in a different fashion. We encourage people to consider foods that have a lower glycemic index.” • Shared decision-making in planning and treatment. Throughout the VA/DOD diabetes care guidelines, there is an emphasis on patient-centered care that takes individual differences into account – an emphasis so important, in fact, that it’s explicitly stated as the first of the 25 97

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■■ As of mid-2017, approximately 1.5 million – 27 percent – of 5.6

U.S. ARMY PHOTO BY ROBERT T. SHIELDS

million veterans who received care through the Veterans Health Administration have diabetes. Individualized blood sugar targets, updated nutrition recommendations, and shared decision-making in treatment are some of the guidelines the VA has devised for care of those with diabetes.

recommendations: “Using shared decision-making, consider all treatment options and develop a treatment plan based on the balance of risks, benefits, and patient-specific goals, values, and preferences.” Rose Mary Pries, Dr.P.H., who manages the Veterans Health Education and Information Program, pointed out that this recommendation’s inclusion in the guidelines was itself the result of input from veteran patients with diabetes. “Almost unanimously,” she said, “patients who currently have diabetes said they wanted to understand diabetes. They wanted to be offered treatment options and to be asked about their preferences related to treatment options. So we used that information from people with diabetes themselves as our foundation for our approach to shared decision-making: Patients, with their providers, their physicians, and their health care team members, work together to create treatment plans that will be safe

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and effective for them, and meet their individual lifestyle goals and preferences.” Of course, being an equal partner in decision-making requires knowledge about both the disease and treatment – and the new guidelines recommend individualized, ongoing education for patients. PUTTING GUIDELINES INTO PRACTICE

Despite all the work, study, and consultation that went into the new VA/DOD “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” document, Pogach pointed out that making recommendations is the easy part: “The transition from having guidelines to making them work,” he said, “is not an easy one.” The persistence of the fixed less than 7 percent A1c target, for example, has prompted the establishment of VA’s voluntary Hypoglycemia Safety Initiative (HSI). Initiatives such as the HSI are enabled, in part, by the VA’s electronic medical record system and the capability to automatically plant reminders or “flags” in the records of individual patients. The HSI was conceived a few years ago by a group of professionals in the VA’s Great Lakes Health Care System, who created a system of warning flags and prompts 99

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that popped up in the records of patients who were at risk for low blood sugar – patients older than 75, for example, or those with cognitive impairment or kidney disease. When the annual A1c test comes due, the VHA’s record system prompts clinicians to decide upon an individualized A1c goal for the patient. Depending on the A1c value, the system also generates a list of appropriate medications and dosages, and a list of questions for the clinician to ask the patient about whether or not they’ve recently had low blood sugar reactions. It may then prompt the provider to ask the patient if they want to relax their therapy, or maintain their medication regimen. The HSI is now operating in about 35 VHA facilities, said Pogach, who noted that it remains “strictly voluntary. It’s meant to be a guide, and not a mandate, to help initiate conversations with patients.” Because those conversations are the key to developing a shared vision for treatment, the VA’s Health Education and Information Program has developed several tools to help veterans with diabetes understand their medical condition and the treatment options they’ll be discussing with providers. The online Veterans Health Library (www.veteranshealthlibrary.org), said Pries, “has two sections: one that discusses diabetes as a medical condition and another section, called Living with Diabetes, that offers patients and family members helpful guidance on how to cope with a chronic disease as complex as diabetes on a day-to-day basis. So we have health sheets that are available for patients. We have videos on partnering with your provider. We have assessment tools. Providers and health care team members can use these tools to help their patients to understand what diabetes is all about.” In July 2017, the VA’s National Center for Health Promotion and Disease Prevention created a compact resource for clinical teams to distribute to patients, called “Ask About Low Blood Sugars” (www.prevention.

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■■ A poster created as part of the Hypoglycemia Safety Initiative gives patients information on

low blood sugar symptoms and how to avoid them.

va.gov/MPT/2017/docs/July_2017_Resource_Document.pdf) that contains links, in a single PDF document, to all the available information resources that a patient who has diabetes might need: the new “Clinical Practice Guideline,” the Veterans Health Library, a guide to shared decision-making, and more. “We package it in a way that’s very easy for the clinical team to use,” Pries said, “because we know they’re busy. And if we don’t package it well, they may not necessarily have time, in a busy clinical encounter with a veteran, to go searching for information on the internet.” By making such resources readily available to veterans with diabetes, VHA hopes to satisfy one of the most significant elements of its new clinical care guidelines: enabling veteran patients to become full partners in determining diabetes treatment goals that will reduce the risk of complications and improve their quality of life. 101