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How the politics of firearms hurt effective conversations about suicide prevention 

From The New York Times: 

The lethal-means provision would have provided mandatory training to nearly all Veterans Affairs doctors and mental health professionals, as well as private doctors who treat patients with veterans’ health benefits.

Like the conversations doctors have had for years with cigarette smokers, the approach involves making sure the patient understands the dangers of easily accessible guns, and then asking whether the patient wants to come up with a plan to reduce those dangers. Suggestions include locking up the guns in the house or storing them with a friend, relative or local gun club until the patient’s risk of suicide has subsided.

The lethal-means safety approach has broad support among major veterans’ groups, and it was included in a list of 10 suicide prevention recommendations released by the White House in the spring.
...
“If you want to really make a dent in preventing suicide, this would have the most impact,” said Russell Lemle, the former chief psychologist for the San Francisco Veterans Affairs hospital system.

For years, he said, the medical profession has generally tried to reduce suicide by treating patients’ underlying mental health issues. But epidemiologists have realized that impressive gains can be made by making the physical act of suicide more difficult and less lethal.

“Suicide is often an impulsive act,” Dr. Lemle said. “If we can put distance between the impulse and the means, we can make a real difference.”
...
Dr. Lemle, who became a senior policy analyst at the Veterans Healthcare Policy Institute after leaving Veterans Affairs last year, said the system’s reluctance to speak openly about the problem of guns had only fueled disinformation.

“The idea is not to restrict anyone,” Dr. Lemle said. “This is not a gun rights issue, it’s about coming up with a mutually derived plan to be safe. For too long, I think we’ve been afraid to talk about it, to the disservice of our patients.”

Commander Hannon, whom the prevention bill is named after, may be a case in point. After a 23-year career serving around the world with the SEALs, he retired in 2011 and moved to Montana, where he struggled for years with post-traumatic stress, traumatic brain injuries and bipolar disorder. He found solace in therapy programs that used animals, and in helping other veterans.

He owned several guns. Out of concern for his safety, his family stored the guns with a fellow SEAL at one point, but he soon demanded them back. His sister, Kim Parrott, said the family never formally learned how to talk to him about the dangers guns pose to veterans with mental health disorders.

“It would have been tough,” Ms. Parrott said, indicating that her brother and other veterans were attached to their firearms. “But I see how that could change.” Read the full article at The New York Times.
 

 

Racial disparities among veterans with COVID19

From VA’s Research Currents:

A team led by VA researchers Dr. Amy Justice and Dr. Christopher Rentsch found that race and ethnicity is associated with a greater risk of testing positive for COVID-19, but not death within a 30-day period after hospital discharge. Justice is a clinical epidemiologist at the West Haven VA Medical Center in Connecticut and Yale University. The study was published in PLOS Medicine on Sept. 22.

The investigators analyzed the electronic health records of 5.8 million Veterans in VA care. Within that group, 254,595 people were tested for COVID-19 between Feb. 8 and July 22, 2020; of those, 16,317 tested positive and 1,057 died.

The team found a substantial excess burden of COVID-19 infection in minority communities. They identified an urgent need to develop state- and local-level strategies to reduce COVID-19 spread in minority groups. "Black and Hispanic individuals were twice as likely to test positive for COVID-19, even after accounting for underlying health conditions, other demographics, and geographic location," said lead author Dr. Christopher Rentsch, who is also an assistant professor at the London School of Hygiene and Tropical Medicine in the United Kingdom.
...
They found that Black and Hispanic Veterans were twice as likely to test positive for COVID-19, compared with their white counterparts. The finding held true even after the researchers accounted for underlying health conditions geographic location, and other demographic factors. However, 30-day mortality (death) rates among infected patients did not differ by race or ethnicity.

Disparities in healthcare for veterans of color. Tuesday, Oct. 20 at 1 p.m. ET

VHPI Forum on Tuesday, Oct. 20 at 1 p.m. ET

Join the discussion about Disparities in Care for Veterans of Color in the Tuesday, October 20 Zoom Forum. Register here. 

Panelists include: 
  • Suzanne Gordon, journalist and author of Wounds of War and The Battle for Veterans' Healthcare
  • Lindsay Church, co-founder and executive director of Minority Veterans of America
  • Melissa Bryant, veterans' advocate, formerly of the American Legion and IAVA
  • Harold Kudler, M.D., former national Mental Health policy lead in the Department of Veterans Affairs’ central office

[Disparities, cont'd] 

More than 250,000 individuals were tested for COVID-19 during the study period; of those, 4.4% of white Veterans were positive for COVID-19, 10.2% of Blacks were positive, and 11.4% of Hispanics were positive. The racial breakdown of study participants who tested positive was 43.9% white, 40.4% Black, and 15.7% Hispanic.

The team was not fully able to explain the reasons behind racial disparities in COVID-19 infection. While 66% of all individuals in the study population lived in urban areas, 87% of those who tested positive were urban residents. Previous studies have found that members of minority groups are more likely to live in high-density cities or multigenerational households where the risk of COVID-19 infection is greater. They are also more likely to work in essential industries, such as public transportation, where the chance of contact with the public is increased.
...
The researchers also found regional differences in disease incidence between Black and white Veterans. COVID-19 disparities for positive test rates in Black Veterans were highest in the Midwest region and lowest in the West. Disparities between the two groups decreased slightly over the study period. The disparity between Hispanic and white Veterans who tested positive was consistent across time, region, and outbreak patterns.

Insurers’ Medicare profits have jumped

From Politico Pro:

Insurer profits on Medicare Advantage have grown 41 percent over last year, with plans grossing an additional $64 per member per month, according to a new Kaiser Family Foundation study.

Plans now gross about $222 per Medicare Advantage member per month, compared to just $138 per member per month in the individual market and $106 per member per month in the group market.

Underlying chronic conditions that contributed to COVID deaths

Veterans are a high risk group because they suffer from complex, co-occurring chronic conditions as a result of their military service. From MDedge:

Although the ongoing number of deaths attributable to COVID-19 continues to garner attention, there can be a lag of weeks or months in how long it takes some public health agencies to update their figures.

“For the public at large, the take-home message is twofold: that the number of deaths caused by the pandemic exceeds publicly reported COVID-19 death counts by 20% and that states that reopened or lifted restrictions early suffered a protracted surge in excess deaths that extended into the summer,” lead author of the US-focused study, Steven H. Woolf, MD, MPH, told Medscape Medical News.

The take-away for physicians is in the bigger picture – it is likely that the COVID-19 pandemic is responsible for deaths from other conditions as well. “Surges in COVID-19 were accompanied by an increase in deaths attributed to other causes, such as heart disease and Alzheimer’s disease and dementia,” said Woolf, director emeritus and senior adviser at the Center on Society and Health and professor in the Department of Family Medicine and Population Health at the Virginia Commonwealth University School of Medicine in Richmond, Virginia.

The investigators identified 225,530 excess US deaths in the 5 months from March to July. They report that 67% were directly attributable to COVID-19.

Deaths linked to COVID-19 included those in which the disease was listed as an underlying or contributing cause. US total death rates are “remarkably consistent” year after year, and the investigators calculated a 20% overall jump in mortality.

VA & DoD near rollout of health record link

Why is this important? One of the big issues behind effective healthcare is effective communication and use of records. The private sector uses many different proprietary and siloed solutions which make the exchange difficult between providers. As Sarah Kliff points out in a 2018 Vox article “Why American medicine still runs on fax machines”, this makes care more costly and inhibits effective care. Innovations at the VA regularly benefits those outside the Veterans Health Administration. Hopefully these innovations can help improve private healthcare. From EHR Intelligence:


In the strategy, FEHRM said VA and DoD would acquire and implement top health IT capabilities that enable health and benefits team members to deliver a seamless healthcare and benefits experience to beneficiaries. Furthermore, both agencies must maintain full control over patient health data.

...
Although the VA’s Electronic Health Record Modernization (EHRM) program will launch within the next few weeks, reports from the Office of Inspector General (OIG) spotlight significant issues surrounding VA’s health information exchanges and its new EHR system.

The OIG HIE report found training challenges, the need for increased community partners, the use of community coordinators, and technology issues that need to be addressed to enhance the VA’s ability to effectively utilize its HIEs and the ability to exchange patient data.

These reports and a basic need for increased interoperability generated a series of VA health IT advancements and optimizations over the past few months.

  • Related: VA-DOD Health Exchange Adds 15,000-Member Hospital Network via NextGov. 

The mental health impact of a prolonged pandemic

From JAMA via MDedge:

Since February 2020, COVID-19 has taken the lives of more than 214,000 Americans. The number of deaths currently attributed to the virus is nearly four times the number of Americans killed during the Vietnam War. The magnitude of death over a short period is a tragedy on a “historic scale,” wrote Dr. Simon and colleagues.

The surge in mental health problems related to COVID-19 deaths will bring further challenges to individuals, families, and communities, including a spike in deaths from suicide and drug overdoses, they warned.

It’s important to consider, they noted, that each COVID-19 death leaves an estimated nine family members bereaved, which is projected to lead to an estimated 2 million bereaved individuals in the United States.

“This interpersonal loss on a massive scale is compounded by societal disruption,” they wrote. The necessary social distancing and quarantine measures implemented to fight the virus have amplified emotional turmoil and have disrupted the ability of personal support networks and communities to come together and grieve.

“Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive disorder and symptoms of posttraumatic stress disorder,” Simon and colleagues said.

“Once established, these conditions can become chronic with additional comorbidities such as substance use disorders. Prolonged grief affects approximately 10% of bereaved individuals, but this is likely an underestimate for grief related to deaths from COVID-19,” they wrote.

As with the first COVID-19 wave, the mental health wave will disproportionately affect Black persons, Hispanic persons, older adults, persons in lower socioeconomic groups of all races and ethnicities, and healthcare workers, they note.

Veterans’ Healthcare Verbatim 

From Andy Berman, Vietnam Veteran:

My worst experience was when, presumably a staffing shortage, led the VA to outsource a part of my care to a private medical provider. The VA discovered that I needed an operation to remove a large sarcoma that lit up under a PET scan, indicative of a cancerous growth under the skin.

I was sent to a local university medical center for the operation, where things did not go well. It was a classic example of the advantages provided by the VA healthcare system over private medical care. The surgeon who performed the operation to remove the cancerous growth was not aware of the side effects of the newly released oral medication I was taking at the time to suppress the CLL. Did he not read my medical records? Was he so specialized that he did not follow the latest developments in leukemia care? I don't know. But his failure to know that my anti-leukemia pills should have been suspended for a week prior to the operation led to serious bleeding for weeks afterward. Had the operation been performed at the VA itself that complication surely would not have happened. Full information about my medical history would have been passed from VA Oncology to VA Surgery which would have been fully aware of the need to temporarily suspend my leukemia medication.

With the coming of the COVID-19 crisis, the Minnesota VA took on the infamous "Fourth Mission" of the Veterans Administration. It began accepting non-veterans needing hospitalization for the COVID-19 virus, providing much needed relief to private sector hospitals. But because of the danger of exposure to the virus at the VA hospital, non-urgent appointments by veterans at the hospital were limited.

Thus my monthly IV infusions could not take place as usual at the VA. To its immense credit, on a monthly basis the VA has sent a nurse to my home with the medicine and equipment to administer the infusion in my living room. I am enormously appreciative of this, which has saved me from possible exposure to COVID-19 at the hospital.

The nurses sent, however, were not VA employees. They were working for a private contractor engaged in providing medical care in home visits. Alas, it was absolutely obvious that they did not have the level of training and skills that I have consistently encountered at the VA itself. While nothing terrible happened, there were some uncomfortable mishaps that left me yearning to return to the VA hospital.

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