Converting a Geriatrics Clinic to Virtual Visits during COVID-19: A Case Study

Background: To characterize the experience of converting a geriatrics clinic to telehealth visits in early stages of a pandemic. Design: An organizational case study with mixed methods evaluation from the first 8 weeks of converting a geriatrics clinic from in-person visits to video and telephone visits. Setting: Veteran’s Health Administration in Northern California Participants Community-dwelling older Veterans receiving care at VA Palo Alto Geriatrics clinic. Veterans had a mean age of 85.7 (SD = 6.8) and 72.1% had cognitive impairment. Intervention: Veterans with face-to-face appointments were converted to video or telephone visits to mitigate exposure to community spread of COVID-19. Measurements: Thirty-two patient evaluations and 80 clinician feedback evaluations were completed. This provided information on satisfaction, care access during pandemic, and travel and time savings. Results: Of the 62 scheduled appointments, 43 virtual visits (69.4%) were conducted. Twenty-six (60.5%) visits were conducted via video, 17 (39.5%) by telephone. Virtual visits saved patients an average of 118.6 minutes each. Patients and providers had similar, positive perceptions about telehealth to in-person visit comparison, limiting exposure, and visit satisfaction. After the telehealth appointment, patients indicated greater comfort with using virtual visits in the future. Thirty-one evaluations included comments for qualitative analysis. We identified 3 main themes of technology set-up and usability, satisfaction with visit, and clinical assessment and communication. Conclusion: During a pandemic that has limited the ability to safely conduct inperson services, virtual formats offer a feasible and acceptable alternative for clinically-complex older patients. Despite potential barriers and additional effort required for telehealth visits, patients expressed willingness to utilize this format. Patients and providers reported high satisfaction, particularly with the ability to access care similar to in-person while staying safe. Investing in telehealth services during a pandemic ensures that vulnerable older patients can access care while maintaining social distancing, an important safety measure.

Safety of High-Intensity Statins in the Veteran Population: Atorvastatin 40 to 80 mg Compared With Rosuvastatin 20 to 40 mg

Background: High-intensity statin therapy is recommended in patients with clinical atherosclerotic cardiovascular disease (ASCVD) or at high risk of ASCVD. Current evidence demonstrates efficacy of high-intensity statin therapy in reducing major adverse cardiovascular events; yet the comparative safety profile between high-intensity statin agents remains unknown. In 2011, when atorvastatin became generic, the Veteran’s Health Administration made the formulary switch from rosuvastatin to atorvastatin. Currently, rosuvastatin is generic; however, at the time of this study, it was still under patent. Objective: The primary objective was to determine if high-intensity atorvastatin compared with rosuvastatin is associated with an increased incidence of adverse drug reactions (ADRs) in the veteran population. Methods: A retrospective cohort study at James A. Haley Veterans’ Hospital compared patients receiving rosuvastatin 20 to 40mg from January 2009 to November 2011 (n = 4,165) and atorvastatin 40 to 80mg from May 2012 to June 2016 (n = 5,852). Patients were excluded if they were nonadherent to statin therapy or had a documented ADR to atorvastatin prior to formulary switch. Results: A difference in overall ADR rates was found between atorvastatin and rosuvastatin groups (4.59% vs 2.91%; odds ratio [OR], 1.61; 95% CI, 1.29 to 2.00; P < 0.05). Statistically significant differences in abnormal liver transaminases (3.99% vs 1.39%; OR, 2.95; 95% CI, 2.21 to 3.94; P < 0.05) and statin-associated muscle symptoms (1.14% vs 0.5%; OR, 2.29; 95% CI, 1.39 to 3.74; P < 0.05) were identified between groups. Patients receiving rosuvastatin were on therapy 2.5 times longer before developing an ADR. Conclusion and Relevance: High-intensity atorvastatin compared with rosuvastatin is associated with an increased incidence of ADRs.

“Don't We Take Care of Our Veterans?” The Critical Need for Veteran's Health Services Infertility Services for Veterans: Policies, Challenges, and Opportunities

Since October 2001, more than 2.7 million men and women of the armed forces have been deployed to Iraq, Afghanistan, or in support of the “Global War on Terrorism.” Like previous wars, our nation will feel the after-effects of those deployments for a generation to come, as the wounds of war do not just affect the veteran, but impact their family and friends once they return to the home front. But unlike previous wars, less than 1% of our population serves their country in an all-volunteer military. This small percentage of Americans who volunteer to serve us and protect our freedoms (no matter what you might think about the politics surrounding wars) is increasingly removed from the rest of the population who choose other careers and options. Therefore, most of us are uneducated and unconnected to the often isolating experiences and frustrations of our veterans when they return to the home front and try to retake the stage of their former lives. In this discussion, we share the compelling stories of military members and veterans who struggle with infertility. We describe the need for policy and expansion of services for infertility care in the Department of Defense and Veterans Health Administration, and the challenges and opportunities that exist.