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Purpose: The coronavirus disease 2019 (COVID-19) pandemic limited healthcare professional education and training opportunities in rural communities. Because the US Department of Veterans Affairs (VA) has robust programs to train clinicians in the United States, this study examined VA trainee perspectives regarding pandemic-related training in rural and urban areas and interest in future employment with the VA., Methods: Survey responses were collected nationally from VA physicians and nursing trainees before and after COVID-19 (2018 to 2021). Logistic regression models were used to test the association between pandemic timing (pre-pandemic or pandemic), trainee program (physician or nurse), and the interaction of trainee pandemic timing and program on VA trainee satisfaction and trainee likelihood to consider future VA employment in rural and urban areas., Results: While physician trainees at urban facilities reported decreases in overall training satisfaction and corresponding decreases in the likelihood of considering future VA employment from pre-pandemic to pandemic, rural physician trainees showed no changes in either outcome. In contrast, while nursing trainees at both urban and rural sites had decreases in training satisfaction associated with the pandemic, there was no corresponding effect on the likelihood of future employment by nurses at either urban or rural VA sites., Conclusion: The study’s findings suggest differences in the training experiences of physicians and nurses at rural sites, as well as between physician trainees at urban and rural sites. Understanding these nuances can inform the development of targeted approaches to address the ongoing provider shortages that rural communities in the United States are facing.

Kainoid natural products are a series of potent ionotropic glutamate receptor agonists produced by a variety of divergent marine micro- and macro-algae. The key biosynthetic step in the construction of the pyrrolidine ring pharmacophore involves a unique branch of non-heme iron α-ketoglutarate dependent dioxygenases (Fe/αKGs) termed the kainoid synthases. These Fe/αKG homologs catalyze a stereoselective C-H abstraction followed by a radical carbon-carbon bond reaction to form the bioactive core on N-prenylated L-glutamic acid substrates. In this article, we describe the expression, purification, and biochemical characterization of four divergent kainoid synthases (DabC, RadC1, DsKabC, GfKabC). Furthermore, we compare and contrast their substrate preferences and product distributions, and provide some preliminary insight into how to repurpose these enzymes for whole cell biocatalysis., (Copyright © 2024. Published by Elsevier Inc.)

Background: The Veterans Affairs (VA) Healthcare System Community Hospital Transitions Program (CHTP) was implemented as a nurse-led intervention to reduce barriers that patients experience when transitioning from community hospitals to VA primary care settings. A previous analysis indicated that veterans who enrolled in CHTP received timely follow-up care and communications that improved care coordination, but did not examine cost implications for the VA., Methods: A budget impact analysis used the VA (payer) perspective. CHTP implementation team members and study records identified key resources required to initially implement and run the CHTP. Statistical analysis of program participants and matched controls at two study sites was used to estimate incremental VA primary care costs per veteran. Using combined program implementation, operations, and healthcare cost estimates to guide key model assumptions, overall CHTP costs were estimated for a 5-year time horizon, including a discount rate of 3%, annual inflation of 2.5%, and a sensitivity analysis that considered two options for staffing the program at VA Medical Center (VAMC) sites., Results: Implementation at two VAMCs required 3 months, including central program support and site-level onboarding, with costs of $34,094 (range: $25,355-$51,602), which included direct and indirect resource costs of personnel time, materials, space, and equipment. Subsequent annual costs to run the program at each site depended heavily on the staffing mix and caseload of veterans, with a baseline estimate of $193,802 to $264,868. Patients enrolled in CHTP had post-hospitalization VA primary care costs that were higher than matched controls. Over 5 years, CHTP sites staffed to serve 25-30 veterans per full-time equivalent transition team member per month had an estimated budget impact of $625 per veteran served if the transitional team included a medical social worker to support veterans with more social behavioral needs and less complex medical cases or $815 per veteran if nurses served all cases., Conclusions: Evidence-based care coordination programs that support patients' return to VA primary care after a community hospital stay are feasible to implement and run. Further, flexibility in staffing this type of program is increasingly relevant as the VA and other healthcare systems consider methods to reduce provider burnout, optimize staffing, reduce costs, and address other staffing challenges while improving patient care., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background : This study aims to describe TBI-related hospitalizations for the whole population and identify factors associated with in-hospital mortality among elderly (≥65 years) patients hospitalized with TBI in Texas. Methods : Using Texas Hospital Discharge Data from 2012 to 2014, TBI-related hospitalizations were identified using International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM) codes. Rates for age and gender were estimated using U.S. Census data. Univariate and multivariate analyses were used to identify factors associated with in-hospital mortality among those aged at least 65 years. Results : There were 51,419 TBI-related hospitalizations from 2012 to 2014 in Texas. Falls were the leading cause of TBI-related hospitalizations 6235 (36.64%), 6595 (38.40%), and 5412 (37.59%) for 2012, 2013, and 2014, respectively. Males had higher rates of hospitalizations while rates were highest for those above 80 years of age. Compared to Whites, Hispanics had 1.18 higher adjusted odds of in-hospital mortality [OR = 1.18: 95% CI (1.01-1.40)]. Similarly, adjusted odds of in-hospital mortality were higher among males [OR = 1.55: 95% CI (1.36-1.77)]. Conclusion : This study provided evidence of demographic disparities in the burden and outcome of TBI in Texas, findings could serve as a foundation for targeted TBI prevention interventions.

Medicare utilization and costs for residents of the U.S. Gulf Coast, who are highly vulnerable to natural disasters, may be impacted by their disaster exposure.To estimate differences in healthcare utilization by disaster exposure, we calculated Medicare expenditures among residents of U.S. Gulf States and compared them with expenditures among residents of other regions of the U.S.Panel models were used to calculate changes in overall Medicare expenditures, inpatient expenditures, and home health expenditures for 32,819 Medicare beneficiaries. Individual demographic characteristics were included as predictors of change in expenditures.Medicare beneficiaries with National Health Interview Survey participation were identified and Part A claims were linked. Federal Emergency Management Agency (FEMA) data was used to determine counties that experienced no, some, high, and extreme hazard exposure. FEMA data was merged with Medicare claims data to create a panel dataset from 2001 to 2007.Medicare Part A claims for the years 2001 to 2007 were merged with FEMA data related to disasters in each U.S. County. Overall Medicare costs, as well as costs for inpatient and home health care for residents of states located along the U.S. Gulf Coast (Texas, Louisiana, Mississippi, Alabama, and Florida) were compared to costs for residents of the rest of the U.S.Expenditures among residents of U.S. Gulf States decreased with increased hazard exposure. Decreases in inpatient expenditures persisted in the years following a disaster.The use of beneficiary-level data highlights the potential for natural hazards to impact health care costs. This study demonstrates the possibility that exposure to more severe disasters may limit access to health care and therefore reduce expenditures. Additional research is needed to determine if there is a substitution of services (e.g., inpatient rehabilitation for home health) in disaster-affected areas during the post-disaster period.

Importance: Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor., Objective: To test a multifaceted intervention to improve adherence to cardiac medications., Design, Setting, and Participants: In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge., Interventions: The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls)., Main Outcomes and Measures: The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P< .001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P = .03), statins (93.2% vs 71.3%; P < .001), and ACEI/ARB (93.1% vs 81.7%; P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals., Conclusions and Relevance: A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program., Trial Registration: clinicaltrials.gov Identifier: NCT00903032.

Background: Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications., Methods and Results: To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises 4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care., Conclusions: If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.

Background: Patients who survive a severe exacerbation of COPD are at high risk of rehospitalization for COPD and death. The objective of this study was to determine predictors of these events in a large cohort of Veterans Affairs (VA) patients., Methods: We identified 51,353 patients who were discharged after an exacerbation of COPD in the VA health-care system from 1999 to 2003, and determined the rates of rehospitalization for COPD and death from all causes. Potential risk factors were assessed with univariate and multivariate survival analysis., Results: On average, the cohort was elderly (mean age, 69 years), predominately white (78% white, 13% black, 3% other, and 6% unknown), and male (97%), consistent with the underlying VA population. The risk of death was 21% at 1 year, and 55% at 5 years. Independent risk factors for death were age, male gender, prior hospitalizations, and comorbidities including weight loss and pulmonary hypertension; nonwhite race and other comorbidities (asthma, hypertension, and obesity) were associated with decreased mortality. The risk of rehospitalization for COPD was 25% at 1 year, and 44% at 5 years, and was increased by age, male gender, prior hospitalizations, and comorbidities including asthma and pulmonary hypertension. Hispanic ethnicity and other comorbidities (diabetes and hypertension) were associated with a decreased risk of rehospitalization., Conclusions: Age, male gender, prior hospitalizations, and certain comorbid conditions were risk factors for death and rehospitalization in patients discharged after a severe COPD exacerbation. Nonwhite race and other comorbidities were associated with decreased risk.

Organized delivery systems are becoming an increasingly important component of urban health care markets and are expanding their influence in rural areas as well. They also are developing new linkages with rural providers. This article, based on the experiences of 20 diverse organizations, identifies and describes the strategies being used by urban systems to redefine linkages with rural hospitals and, particularly, physicians.

This study analyzes the changes in costs and prices from 1986 to 1994 for more than 3,500 U.S. short-term general hospitals, including 122 horizontal mergers. These mergers were generally financially beneficial to consumers, providing average price reductions of approximately 7 percent. Merger-related price reductions were considerably less in market areas with higher market concentration levels. Merger-related price reductions in areas with higher penetration by health maintenance organizations (HMOs) were approximately twice those in areas with lower HMO penetration. Merger-related price reductions were greater for low-occupancy hospitals, nonteaching hospitals, nonsystem hospitals, similar-size hospitals, and hospitals with greater premerger service duplication.