User login
VAM ’17 Will Be a ‘Spectacular Meeting’
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Participants at the Vascular Annual Meeting (VAM) have lots more to look forward to than sunny skies, beaches and palm trees. A number of new program features are planned to add interest and value to the meeting, said Dr. Ron Dalman.
Dr. Dalman chairs the SVS Program Committee, which develops programming and content for VAM, the premiere meeting for vascular specialists.
The 2017 meeting will be May 31-June 3 in beautiful San Diego, with plenaries and exhibits set for June 1-3.
Changes for 2017 include:
• More and potentially longer sessions with collaborative specialty societies, such as the American Venous Forum, the Society for Vascular Ultrasound and the Society of Thoracic Surgeons. “These sessions provide a multi-disciplinary perspective on our common problems and showcase the SVS’ leadership role in vascular health and disease management,” said Dr. Dalman. Members provided positive feedback on last year’s partnership sessions, so this year, these program features will be significantly expanded.
• An educational review course highlighting some of the more frequently missed questions from the latest version of the Vascular Education Self-Assessment Program (VESAP3).
• Guideline summaries, organized by the SVS Document Oversight Committee and presented by the authorship group for each, on critical topics such as abdominal aortic aneurysms, aortic dissection, venous disease and more. These summaries will be incorporated into post-graduate programming. “It makes sense to cover current practice guidelines and consensus documents, as several high-profile efforts are being updated this year,” said Dr. Dalman. “We can give attendees an executive summary of current guidelines by their respective authors, and attendees will come away with unique insights into why the most impactful and significant changes were included in each respective document.”
• Sessions of potential interest to surgeons in community practice environments, marked in the schedule as such by the SVS Community Practice Committee.
“These improvements will increase the value of the Annual Meeting for all attendees,” Dr. Dalman said. “We’re emphasizing interactive education, not simply passive learning. It’s going to be very exciting – and different in both style and substance.”
A Californian himself, Dr. Dalman also is looking forward to showing off his state. “San Diego is a wonderful place to vacation and the meeting venue provides convenient access to the Gaslamp District, the waterfront and the world-famous beaches,” he said.
“We encourage our members to bring their families to San Diego and make a vacation out of it.”
With the programming additions, increased opportunities for participation, the educational activities planned plus the perfect location, he added, “This is going to be a spectacular meeting.”
Ready for post-acute care?
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
The definition of “hospitalist,” according to the SHM website, is a clinician “dedicated to delivering comprehensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and post-acute care (PAC) in the United States has grown, more hospitalists are extending their roles into this space.
PAC today is more than the traditional nursing home, according to Manoj K. Mathew, MD, SFHM, national medical director of Agilon Health in Los Angeles.
Many of those expanded settings Dr. Mathew describes emerged as a result of the Affordable Care Act. Since its enactment in 2010, the ACA has heightened providers’ focus on the “Triple Aim” of improving the patient experience (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.1 Vishal Kuchaculla, MD, New England regional post-acute medical director of Knoxville,Tenn.-based TeamHealth, says new service lines also developed as Medicare clamped down on long-term inpatient hospital stays by giving financial impetus to discharge patients as soon as possible.
“Over the last few years, there’s been a major shift from fee-for-service to risk-based payment models,” Dr. Kuchaculla says. “The government’s financial incentives are driving outcomes to improve performance initiatives.”
“Today, LTACHs can be used as substitutes for short-term acute care,” says Sean R. Muldoon, MD, MPH, FCCP, chief medical officer of Kindred Healthcare in Louisville, Ky., and former chair of SHM’s Post-Acute Care Committee. “This means that a patient can be directly admitted from their home to an LTACH. In fact, many hospice and home-care patients are referred from physicians’ offices without a preceding hospitalization.”
Hospitalists can fill a need
More hospitalists are working in PACs for a number of reasons. Dr. Mathew says PAC facilities and services have “typically lacked the clinical structure and processes to obtain the results that patients and payors expect.
“These deficits needed to be quickly remedied as patients discharged from hospitals have increased acuity and higher disease burdens,” he adds. “Hospitalists were the natural choice to fill roles requiring their expertise and experience.”
Dr. Muldoon considers the expanded scope of practice into PACs an additional layer to hospital medicine’s value proposition to the healthcare system.
“As experts in the management of inpatient populations, it’s natural for hospitalists to expand to other facilities with inpatient-like populations,” he says, noting SNFs are the most popular choice, with IRFs and LTACHs also being common places to work. Few hospitalists work in home care or hospice.
PAC settings are designed to help patients who are transitioning from an inpatient setting back to their home or other setting.
“Many patients go home after a SNF stay, while others will move to a nursing home or other longer-term care setting for the first time,” says Tiffany Radcliff, PhD, a health economist in the department of health policy and management at Texas A&M University School of Public Health in College Station. “With this in mind, hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting.”
Transitioning Care
Even if a hospitalist is not employed at a PAC, it’s important that they know something about them.
“As patients are moved downstream earlier, hospitalists are being asked to help make a judgment regarding when and where an inpatient is transitioned,” Dr. Muldoon says. As organizations move toward becoming fully risk capable, it is necessary to develop referral networks of high-quality PAC providers to achieve the best clinical outcomes, reduce readmissions, and lower costs.2“Therefore, hospitalists should have a working knowledge of the different sites of service as well as some opinion on the suitability of available options in their community,” Dr. Muldoon says. “The hospitalist can also help to educate the hospitalized patient on what to expect at a PAC.”
If a patient is inappropriately prepared for the PAC setting, it could lead to incomplete management of their condition, which ultimately could lead to readmission.
“When hospitalists know how care is provided in a PAC setting, they are better able to ensure a smoother transition of care between settings,” says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health in Long Island, N.Y. “This will ultimately prevent unnecessary readmissions.”
Further, the quality metrics that hospitals and thereby hospitalists are judged by no longer end at the hospital’s exit.
“The ownership of acute-care outcomes requires extending the accountability to outside of the institution’s four walls,” Dr. Mathew says. “The inpatient team needs to place great importance on the transition of care and the subsequent quality of that care when the patient is discharged.”
Robert W. Harrington Jr., MD, SFHM, chief medical officer of Plano, Texas–based Reliant Post-Acute Care Solutions and former SHM president, says the health system landscapes are pushing HM beyond the hospitals’ walls.
How PAC settings differ from hospitals
Practicing in PAC has some important nuances that hospitalists from short-term acute care need to get accustomed to, Dr. Muldoon says. Primarily, the diagnostic capabilities are much more limited, as is the presence of high-level staffing. Further, patients are less resilient to medication changes and interventions, so changes need to be done gradually.
“Hospitalists who try to practice acute-care medicine in a PAC setting may become frustrated by the length of time it takes to do a work-up, get a consultation, and respond to a patient’s change of condition,” Dr. Muldoon says. “Nonetheless, hospitalists can overcome this once recognizing this mind shift.”
According to Dr. Harrington, another challenge hospitalists may face is the inability of the hospital’s and PAC facility’s IT platforms to exchange electronic information.
“The major vendors on both sides need to figure out an interoperability strategy,” he says. “Currently, it often takes 1-3 days to receive a new patient’s discharge summary. The summary may consist of a stack of paper that takes significant time to sort through and requires the PAC facility to perform duplicate data entry. It’s a very highly inefficient process that opens up the doors to mistakes and errors of omission and commission that can result in bad patient outcomes.”
Arif Nazir, MD, CMD, FACP, AGSF, chief medical officer of Signature HealthCARE and president of SHC Medical Partners, both in Louisville, Ky., cites additional reasons the lack of seamless communication between a hospital and PAC facility is problematic. “I see physicians order laboratory tests and investigations that were already done in the hospital because they didn’t know they were already performed or never received the results,” he says. “Similarly, I see patients continue to take medications prescribed in the hospital long term even though they were only supposed to take them short term. I’ve also seen patients come to a PAC setting from a hospital without any formal understanding of their rehabilitative period and expectations for recovery.”
What’s ahead?
Looking to the future, Surafel Tsega, MD, clinical instructor at Mount Sinai Hospital in New York, says he thinks there will be a move toward greater collaboration among inpatient and PAC facilities, particularly in the discharge process, given that hospitals have an added incentive to ensure safe transitions because reimbursement from the Centers for Medicare & Medicaid Services is tied to readmissions and there are penalties for readmission. This involves more comprehensive planning regarding “warm handoffs” (e.g., real-time discussions with PAC providers about a patient’s hospital course and plan of care upon discharge), transferring of information, and so forth.
And while it can still be challenging to identify high-risk patients or determine the intensity and duration of their care, Dr. Mathew says risk-stratification tools and care pathways are continually being refined to maximize value with the limited resources available. In addition, with an increased emphasis on employing a team approach to care, there will be better integration of non-medical services to address the social determinants of health, which play significant roles in overall health and healing.
“Working with community-based organizations for this purpose will be a valuable tool for any of the population health–based initiatives,” he says.
Dr. Muldoon says he believes healthcare reform will increasingly view an inpatient admission as something to be avoided.
“If hospitalization can’t be avoided, then it should be shortened as much as possible,” he says. “This will shift inpatient care into LTACHs, SNFs, and IRFs. Hospitalists would be wise to follow patients into those settings as traditional inpatient census is reduced. This will take a few years, so hospitalists should start now in preparing for that downstream transition of individuals who were previously inpatients.”
The cost of care, and other PAC facts and figures
The amount of money that Medicare spends on post-acute care (PAC) has been increasing. In 2012, 12.6% of Medicare beneficiaries used some form of PAC, costing $62 billion.2 That amounts to the Centers for Medicare & Medicaid Services spending close to 25% of Medicare beneficiary expenses on PAC, a 133% increase from 2001 to 2012. Among the different types, $30.4 billion was spent on skilled nursing facilities (SNFs), $18.6 billion on home health, and $13.1 billion on long-term acute care (LTAC) and acute-care rehabilitation.2
It’s also been reported that after short-term acute-care hospitalization, about one in five Medicare beneficiaries requires continued specialized treatment in one of the three typical Medicare PAC settings: inpatient rehabilitation facilities (IRFs), LTAC hospitals, and SNFs.3
What’s more, hospital readmission nearly doubles the cost of an episode, so the financial implications for organizations operating in risk-bearing arrangements are significant. In 2013, 2,213 hospitals were charged $280 million in readmission penalties.2
References
1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at: http://www.aha.org/research/reports/tw/15dec-tw-postacute.pdf. Accessed Nov. 7, 2016.
2. Post-acute care integration: Today and in the future. DHG Healthcare website. Available at: http://www2.dhgllp.com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. Accessed Nov. 7, 2016.
3. Overview: Post-acute care transitions toolkit. Society for Hospital Medicine website. Available at: http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Accessed Nov. 10, 2016.
Transplantation palliative care: The time is ripe
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Over 10 years ago, a challenge was made in a surgical publication for increased collaboration between the fields of transplantation and palliative care.1
Since that time not much progress has been made bringing these fields together in a consistent way that would mutually benefit patients and the specialties. However, other progress has been made, particularly in the field of palliative care, which could brighten the prospects and broaden the opportunities to accomplish collaboration between palliative care and transplantation.
Growth of palliative services
During the past decade there has been a robust proliferation of hospital-based palliative care programs in the United States. In all, 67% of U.S. hospitals with 50 or more beds report palliative care teams, up from 63% in 2011 and 53% in 2008.
Only a decade ago, critical care and palliative care were generally considered mutually exclusive. Evidence is trickling in to suggest that this is no longer the case. Although palliative care was not an integral part of critical care at that time, patients, families, and even practitioners began to demand these services. Cook and Rocker have eloquently advocated the rightful place of palliative care in the ICU.2
Studies in recent years have shown that the integration of palliative care into critical care decreases in length of ICU and hospital stay, decreases costs, enhances patient/family satisfaction, and promotes a more rapid consensus about goals of care, without increasing mortality. The ICU experience to date could be considered a reassuring precedent for transplantation palliative care.
Integration of palliative care with transplantation
Early palliative care intervention has been shown to improve symptom burden and depression scores in end-stage liver disease patients awaiting transplant. In addition, early palliative care consultation in conjunction with cancer treatment has been associated with increased survival in non–small-cell lung cancer patients. It has been demonstrated that early integration of palliative care in the surgical ICU alongside disease-directed curative care can be accomplished without change in mortality, while improving end-of-life practice in liver transplant patients.3
What palliative care can do for transplant patients
What does palliative care mean for the person (and family) awaiting transplantation? For the cirrhotic patient with cachexia, ascites, and encephalopathy, it means access to the services of a team trained in the management of these symptoms. Palliative care teams can also provide psychosocial and spiritual support for patients and families who are intimidated by the complex navigation of the health care system and the existential threat that end-stage organ failure presents to them. Skilled palliative care and services can be the difference between failing and extended life with a higher quality of life for these very sick patients
Resuscitation of a patient, whether through restoration of organ function or interdicting the progression of disease, begins with resuscitation of hope. Nothing achieves this more quickly than amelioration of burdensome symptoms for the patient and family.
The barriers for transplant surgeons and teams referring and incorporating palliative care services in their practices are multiple and profound. The unique dilemma facing the transplant team is to balance the treatment of the failing organ, the treatment of the patient (and family and friends), and the best use of the graft, a precious gift of society.
Palliative surgery has been defined as any invasive procedure in which the main intention is to mitigate physical symptoms in patients with noncurable disease without causing premature death. The very success of transplantation over the past 3 decades has obscured our memory of transplantation as a type of palliative surgery. It is a well-known axiom of reconstructive surgery that the reconstructed site should be compared to what was there, not to “normal.” Even in the current era of improved immunosuppression and posttransplant support services, one could hardly describe even a successful transplant patient’s experience as “normal.” These patients’ lives may be extended and/or enhanced but they need palliative care before, during, and after transplantation. The growing availability of trained palliative care clinicians and teams, the increased familiarity of palliative and end-of-life care to surgical residents and fellows, and quality metrics measuring palliative care outcomes will provide reassurance and guidance to address reservations about the convergence of the two seemingly opposite realities.
A modest proposal
We propose that palliative care be presented to the entire spectrum of transplantation care: on the ward, in the ICU, and after transplantation. More specific “triggers” for palliative care for referral of transplant patients should be identified. Wentlandt et al.4 have described a promising model for an ambulatory clinic, which provides early, integrated palliative care to patients awaiting and receiving organ transplantation. In addition, we propose an application for grant funding for a conference and eventual formation of a work group of transplant surgeons and team members, palliative care clinicians, and patient/families who have experienced one of the aspects of the transplant spectrum. We await the subspecialty certification in hospice and palliative medicine of a transplant surgeon. Outside of transplantation, every other surgical specialty in the United States has diplomates certified in hospice and palliative medicine. We await the benefits that will accrue from research about the merging of these fields.
1. Molmenti EP, Dunn GP: Transplantation and palliative care: The convergence of two seemingly opposite realities. Surg Clin North Am. 2005;85:373-82.
2. Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370:2506-14.
3. Lamba S, Murphy P, McVicker S, Smith JH, and Mosenthal AC. Changing end-of-life care practice for liver transplant patients: structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage. 2012; 44(4):508-19.
4. Wentlandt, K., Dall’Osto, A., Freeman, N., Le, L. W., Kaya, E., Ross, H., Singer, L. G., Abbey, S., Clarke, H. and Zimmermann, C. (2016), The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Nov 4; doi: 10.1111/ctr.12838.
Dr. Azoulay is a transplantation specialist of Assistance Publique – Hôpitaux de Paris, and the University of Paris. Dr. Dunn is medical director of the Palliative Care Consultation Service at the University of Pittsburgh Medical Center Hamot, and vice-chair of the ACS Committee on Surgical Palliative Care.
Best Practices: Protecting Dry Vulnerable Skin with CeraVe® Healing Ointment
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
A supplement to Dermatology News. This advertising supplement is sponsored by Valeant Pharmaceuticals.
- Reinforcing the Skin Barrier
- NEA Seal of Acceptance
- A Preventative Approach to Dry, Cracked Skin
- CeraVe Ointment in the Clinical Setting
Faculty/Faculty Disclosure
Sheila Fallon Friedlander, MD
Professor of Clinical Dermatology & Pediatrics
Director, Pediatric Dermatology Fellowship Training Program
University of California at San Diego School of Medicine
Rady Children’s Hospital,
San Diego, California
Dr. Friedlander was compensated for her participation in the development of this article.
CeraVe is a registered trademark of Valeant Pharmaceuticals International, Inc. or its affiliates.
Case Series of Patients With Cardiac Amyloidosis at VA New York Harbor Healthcare-Brooklyn
Case Series of Patients With Cardiac Amyloidosis at VA New York Harbor Healthcare-Brooklyn
Transthyretin amyloid cardiomyopathy (ATTR-CM) is caused by the misfolding of the TTR protein, which results in aggregation of amyloid fibrils that deposit in the myocardium and causes restrictive cardiomyopathy. Though it remains underdiagnosed, ATTR-CM is increasingly being recognized as a cause of heart failure in geriatric patients.1 There are 2 categories of ATTRCM: wild-type ATTR-CM (wtATTR-CM), in which there is no mutation in the TTR gene, and hereditary ATTR-CM (hATTR-CM), in which a mutation is present in the TTR gene. Research has shown that wtATTR-CM accounted for as many as 30% of cases of heart failure (HF) with preserved ejection fraction (HFpEF) in patients aged > 75 years.2 A significant percentage of the veteran patient population consists of older males. Given their age, these patients are at greater risk for ATTR diagnosis.3
Identifying red flags for patients within this population may allow clinicians to make earlier diagnoses and improve outcomes. A high index of suspicion is needed to diagnose ATTR because many early signs and symptoms are extracardiac, which leads to delayed diagnoses and worse outcomes. This article describes 8 cases of ATTR-CM within the US Department of Veterans Affairs (VA) New York Harbor Healthcare System-Brooklyn (VANYHHSB).
Methods
This retrospective case series was reviewed and approved by the VANYHHSB Institutional Review Board where it was conducted. Patients diagnosed with ATTR between 2017 and 2024 were identified using International Classification of Diseases, Tenth Revision codes. Eleven patients were identified; 3 were excluded due to insufficient medical records. The remaining 8 patient records were retrospectively reviewed and included.
Case 1
A 67-year-old male with a history of carpal tunnel syndrome (CTS) presented following a syncopal episode. Initial electrocardiogram (ECG) showed sinus rhythm, first-degree atrioventricular block, and a bifascicular block. Transthoracic echocardiogram (TTE) showed moderate asymmetric left ventricular (LV) hypertrophy (LVH) and biatrial enlargement with an ejection fraction (EF) > 55%. The patient was discharged with a loop recorder and an outpatient follow-up appointment scheduled. One month later, he presented with worsening dyspnea on exertion with clinical signs of hypervolemia. A repeat TTE showed global LV wall thickening, moderately reduced LV systolic function (EF 40%), and moderate pulmonary hypertension. Given these findings, the patient underwent cardiac magnetic resonance imaging (CMR), which suggested an infiltrative cardiomyopathy. Amyloid light-chain (AL) amyloidosis evaluation, technetium-99m (99mTC) pyrophosphate imaging, and a fat pad biopsy were unrevealing. An endomyocardial biopsy was performed with electron microscopy, which confirmed amyloidosis. Genetic testing was negative, and the patient began taking tafamidis. There were no later admissions for decompensated HF; however, the patient developed atrial fibrillation (AF) and an interval TTE demonstrated no improvement in his EF. He died at age 73 years.
Case 2
A 78-year-old male with a history of CTS presented with lightheadedness. Initial ECG showed rate-controlled AF and TTE revealed a moderately thickened LV wall with normal LV size, mild left atrial enlargement, and an EF of 65%. The patient was discharged with a scheduled outpatient CMR appointment; however, he defaulted from follow-up. Two years later, he presented with recurrent syncopal episodes and physical examination was consistent with hypervolemia. Repeat TTE revealed moderate LVH, biatrial enlargement, and an EF of 55%. An inpatient CMR was suggestive of cardiac amyloidosis, and a pyrophosphate scan was diagnostic for ATTR. The patient started taking tafamidis, but continued to have recurrent admissions for HF exacerbation. He died at age 81 years.
Case 3
A 71-year-old male with a history of CTS presented with exertional dyspnea. The initial ECG showed sinus rhythm with left atrial enlargement and left axis deviation. Subsequent TTE revealed severe LVH, mildly reduced LV cavity size, moderate to severe biatrial enlargement, and an EF of 25% to 30%. Outpatient 99mTC pyrophosphate imaging suggested cardiac amyloidosis, and laboratory testing showed no evidence of monoclonal proteins. The patient was started on tafamidis for ATTR. At 2-year follow-up, he had new AF and to date has had no further hospitalizations for acute decompensated HF.
Case 4
A 92-year-old male with a history of AF and bilateral CTS presented with lightheadedness. An ECG revealed AF with a slowed ventricular response. Subsequent Holter monitoring demonstrated pauses exceeding 3 seconds, and a permanent pacemaker was recommended. During his preoperative evaluation, TTE revealed severe concentric LVH with a speckled appearance of the myocardium, mild-tomoderate biatrial enlargement, and an EF of 50% to 55%. 99mTC pyrophosphate imaging was positive for amyloidosis and the patient started taking tafamidis. Recurrent hospital admissions for decompensated HF complicated his progression. The patient died at age 95 years.
Case 5
A 72-year-old male with a history of bilateral CTS and cervical spinal stenosis presented with dyspnea on exertion. An ECG revealed a normal sinus rhythm. A TTE found severely reduced systolic function with an EF ≤ 25%, mild concentric LVH, grade 3 diastolic dysfunction, mild-tomoderate biatrial enlargement, and moderate pulmonary hypertension (Figure 1). He was started on guideline-directed medical therapy (GDMT) for HF, which included sacubitril/valsartan, metoprolol succinate, and empagliflozin. The patient’s dyspnea improved, and a workup for nonischemic cardiomyopathy was initiated. 99mTC pyrophosphate imaging 1 year after his initial presentation was positive, leading to ATTR-CM diagnosis. The patient started taking tafamidis and he has since had a stable progression and continued to demonstrate good exercise tolerance with no hospitalizations. His most recent TTE indicated an EF of 40% to 45%.
(parasternal long axis view) of patient 5
demonstrating concentric left ventricular
hypertrophy with a speckled myocardium
and dilated left atrium.
Case 6
A 76-year-old male with a history of paroxysmal AF status after multiple ablations, bilateral CTS, and severe cervical spinal stenosis presented with dyspnea on exertion. The patient’s ECG showed normal sinus rhythm and left axis deviation with concern for left anterior hemiblock. A TTE revealed moderate LVH with a speckled appearance of the myocardium and grade 3 diastolic dysfunction with preserved EF. Before completing the workup for underlying cardiomyopathy, the patient underwent an interventional radiology procedure for an angiomyolipoma, and his postoperative course was complicated by pulmonary edema, requiring admission to the coronary care unit for diuresis. A repeat TTE revealed a reduced EF of 35%, and he was discharged on GDMT. No monoclonal protein was seen in the serum or urine. The patient’s progression was complicated by recurrent admissions for acute decompensated HF and supraventricular tachycardia despite being on amiodarone, which led to a delay in obtaining 99mTC pyrophosphate imaging. Due to hypotension, the patient was unable to tolerate GDMT. He eventually underwent 99mTC pyrophosphate imaging that confirmed ATTR-CM and was started on tafamidis. One year following initial presentation, the patient’s EF progressively declined to 20% to 25%, and he died shortly after discharge to subacute rehabilitation.
Case 7
A 95-year-old male with a history of longstanding persistent AF and bilateral CTS presented with dyspnea on exertion, bendopnea, and worsening bilateral pedal edema for a week. An ECG showed AF with a controlled ventricular response and low-voltage QRS waves (Figure 2). A TTE showed biatrial enlargement, LVH, and preserved EF > 55%. He started taking furosemide and was discharged with a diagnosis of HFpEF. The patient missed cardiology follow-up and presented 1 year later with decompensated HF. An amyloidosis workup was recommended, but due to intermittent periods of being lost to follow-up, the patient did not pursue this workup until 3 years after his initial presentation when 99mTC pyrophosphate imaging confirmed ATTR-CM. The patient declined tafamidis and continued to be followed by the cardiology team. His HF is managed with furosemide as needed due to intolerance to GDMT.
demonstrating atrial fibrillation with controlled
ventricular response and low-voltage QRS.
Case 8
A 74-year-old male with history of bilateral CTS presented with right-sided chest pain associated with shortness of breath, diaphoresis, dizziness, and worsening abdominal pain. He was found to have inferior wall myocardial infarction on ECG with later percutaneous coronary intervention to the left circumflex. His hospital course was complicated by decompensated HF (EF 45% to 50%) and AF with rapid ventricular response. He was treated and discharged with follow-up visits scheduled in the cardiology clinic. Multiple attempts were made to place him on GDMT; however, the patient was unable to tolerate these medications due to recurrent admissions for syncope. During a cardiology clinic visit 3 years after his initial presentation, an amyloidosis workup was initiated. 99mTC pyrophosphate imaging was positive for ATTR-CM, and he started taking tafamidis. Before this diagnosis, ECG indicated low-voltage QRS complexes. His progression has since been complicated by admissions for decompensated HF, recurrent episodes of AF requiring atrioventricular node ablation, and biventricular implantable cardioverter-defibrillator implantation after failed attempts at electrical cardioversion. He continued to follow up in the HF clinic.
Discussion
ATTR-CM is an underdiagnosed cause of cardiomyopathy, particularly in older adults. TTR is a transport protein produced in the liver, and misfolding can occur due to age-related instability of the wild-type protein (wtATTR) or pathologic variants in the TTR (hATTR). The misfolding leads to restrictive physiology, HF (often with preserved EF) arrhythmias, and conduction system disease.1 It is likely that the predominantly older male veteran population would be predisposed to wtATTR cardiomyopathy given that misfolding in the condition is believed to be age-related.
Current criteria for ATTR diagnosis require a combination of clinical suspicion, imaging, laboratory testing, and, in some cases, tissue biopsy confirmation and genetic testing.1,4,5 The diagnostic algorithm is as follows:
Clinical suspicion. Consider ATTR in patients with unexplained HFpEF, LV wall thickness ≥ 12 to 14 mm, discordance between ECG voltage and wall thickness, or associated extracardiac manifestations such as CTS, lumbar spinal stenosis, or peripheral/ autonomic neuropathy.
Exclusion of AL amyloidosis. Bone scintigraphy alone cannot distinguish between AL amyloidosis and ATTR, so patients with suspected amyloid cardiomyopathy should undergo serum and urine immunofixation electrophoresis and serum free light chain assay to rule out a monoclonal gammopathy as seen in AL amyloidosis.
Cardiac scintigraphy. Once AL amyloidosis is excluded, a positive 99mTC-labeled boneavid tracer image (such as a pyrophosphate scan) with grade 2 or grade 3 myocardial uptake is diagnostic of ATTR.
Tissue biopsy. If there is monoclonal gammopathy or equivocal imaging, tissue biopsy (eg, endomyocardial) with Congo red staining and amyloid typing by mass spectrometry or immunohistochemistry is necessary.
Genetic testing. Once ATTR is confirmed, genetic testing distinguishes hATTR from wtATTR, which impacts management and determines the need to screen family members.
Currently, there are 3 therapies approved by the US Food and Drug Administration (FDA) to treat ATTR-CM: tafamidis, acoramidis, and vutrisiran.6-8 Tafamidis and acoramidis stabilize the TTR tetramer, preventing amyloid formation. Vutrisiran uses RNA interference to silence the gene that produces TTR. Tafamidis has been found to improve cardiovascular outcomes in ATTR-CM. In the ATTR-ACT trial, it reduced all-cause mortality and cardiovascular hospitalizations in patients with ATTR-CM and New York Heart Association class I-III symptoms.6 There are other disease-modifying therapies, such the TTR gene silencers inotersen and patisiran; however, these are only FDA-approved for hATTR polyneuropathy and not for ATTRCM; ongoing trials are evaluating their cardiac efficacy.
The mean age of ATTR-CM diagnosis in the patients described in this case series was 79 years, which is older than the mean age of 74 years reported in prior research.4 All patients were male, and the most common presenting symptom was dyspnea on exertion. Table 1 outlines baseline characteristics and associated comorbidities of patients in this case series. The patients presented with many red-flag signs of ATTR-CM (Figure 3). Among them included syncope (4 of 8 patients), spinal stenosis (2 of 8 patients), arrhythmia (7 of 8 patients), heart failure (7 of 8 patients), and bilateral CTS (all patients).
amyloidosis red-flag signs identified.
Bilateral CTS was diagnosed in all patients before their diagnosis of ATTR-CM. Patient 7 had a diagnosis of CTS 9 years before his ATTR-CM diagnosis, underscoring a subtle, yet important extracardiac sign that may increase clinical suspicion for ATTR-CM. Previous research found that the probability of having CTS is highest 5 to 9 years prior to the development of cardiomyopathy. Its presence is also a prognostic marker in ATTR, independent of cardiac involvement.9 The median interval between CTS diagnosis and cardiomyopathy diagnosis was 5 years in this series.
Although screening criteria for ATTR have been proposed, none have been incorporated into formal guidelines.10,11 We propose that a baseline ECG and screening TTE be obtained in any patient aged > 65 years with cardiac risk equivalents such as hypertension and diabetes, presenting with ≥ 1 extracardiac red-flag signs, such as bilateral CTS and spinal stenosis. This will likely facilitate an earlier diagnosis of ATTR-CM, leading to earlier treatment initiation and better patient outcomes. This initiative can be started in the primary care setting and facilitates early cardiology referral. This recommendation is based on literature supporting clinical patterns and observations the authors have made in clinical practice.
Obstructive sleep apnea (OSA) was a comorbidity present in 50% of the patients described in this case series. The literature describing this association is sparse; however, a prospective observational study reported that disorders of sleep inclusive of OSA are frequent in patients with cardiac amyloidosis.12 A theory behind this association is that amyloid deposits in the upper airway tissues lead to airway narrowing. 13 More research is needed to further assess the relationship between OSA and cardiac amyloidosis, particularly with respect to the timing of OSA prior to the development of cardiomyopathy as it may be a potential early sign for clinicians to acknowledge.
An important observation from this case series is the variability in the timing of tafamidis initiation relative to symptom onset and confirmed diagnosis of ATTR-CM (Table 2). Although tafamidis has been found to slow disease progression, several patients in this series began treatment at advanced stages or years after the onset of cardiac symptoms, potentially limiting its clinical benefit.
For example, patient 1 was diagnosed with ATTR 2 years before tafamidis became available on the market and was initially treated with diflunisal. Patients who started tafamidis earlier in the disease course (eg, patients 3 and 5) appeared to have better long-term outcomes, including an absence of heart failure hospitalizations after initiation. In contrast, patients with delayed treatment initiation (eg, patients 2, 6, and 8) experienced ongoing decompensations or early mortality. Patient 7 declined tafamidis, underscoring challenges in medication uptake among older adults. Randomized controlled trials are warranted to compare the effectiveness of tafamidis with other recently FDA-approved therapies, such as acoramidis and vutrisiran, particularly in terms of cardiovascular outcomes.
AF was the most common arrhythmia observed in these patients and may occur years before the development of HF symptoms in the setting of ATTR-CM. Due to inherent conduction system disease, AF in this population may have a controlled or slow ventricular response, as observed in patient 4. Patients with atrial fibrillation and cardiac amyloidosis should receive anticoagulation regardless of CHA2DS2- VASc score due to their high risk of intracardiac thrombus formation.4
Limitations
This case series lacked genetic testing following a confirmed ATTR-CM diagnosis. Although much of the treatment is the same regardless of the presence of a TTR mutation, knowing the specific subtype of ATTR-CM has implications for prognosis and for screening family members.
Conclusions
Following analysis of 8 patients diagnosed with ATTR, this case series could serve as a blueprint for research into ATTR in veterans. In clinical practice, following military service, veterans may not be routinely seen by an outpatient physician and may present with sequelae of advanced stages of ATTR. Early identification of red-flag symptoms can lead to a higher clinical suspicion, prompting early diagnostic evaluation and treatment initiation and ultimately mitigating adverse outcomes. Future research that includes genetic testing for those with confirmed ATTR-CM may prove useful as a foundation for detailed and informed discussions with patients and their families regarding prognosis and, if indicated, screening for family members.
- Kittleson MM, Maurer MS, Ambardekar AV, et al. Cardiac amyloidosis: evolving diagnosis and management: a scientific statement from the American Heart Association. Circulation. 2020;142:e7-e22. doi:10.1161/CIR.0000000000000792
- Dharmarajan K, Maurer MS. Transthyretin cardiac amyloidoses in older North Americans. J Am Geriatr Soc. 2012;60:765-774. doi:10.1111/j.1532-5415.2011.03868.x
- Nativi-Nicolau J, Redd A, Kelly N, et al. Increasing number of amyloidosis diagnosis in the Veterans Affairs populations. J Card Fail. 2019;25:S96.
- Ruberg FL, Grogan M, Hanna M, et al. Transthyretin amyloid cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol. 2019;73:2872-2891. doi:10.1016/j.jacc.2019.04.003
- Gillmore JD, Maurer, Falk RH, et al. Nonbiopsy diagnosis of cardiac transthyretin amyloidosis. Circulation. 2016;133:2404-2412. doi:10.1161/CIRCULATIONAHA.116.021612
- Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy. N Engl J Med. 2018;379:1007-1016. doi:10.1056/NEJMoa1805689
- Gillmore JD, Judge DP, Cappelli F, et al. Efficacy and safety of acoramidis in transthyretin amyloid cardiomyopathy. N Engl J Med. 2024;390:132-142. doi:10.1056/NEJMoa2305434
- Fontana M, Berk JL, Gillmore JD, et al. Vutrisiran in patients with transthyretin amyloidosis with cardiomyopathy. N Engl J Med. 2025;392:33-44. doi:10.1056/NEJMoa2409134
- Milandri A, Farioli A, Gagliardi C, et al. Carpal tunnel syndrome in cardiac amyloidosis: implications for early diagnosis and prognostic role across the spectrum of aetiologies. Eur J Heart Fail. 2020;22:507-515. doi:10.1002/ejhf.1742
- Garcia-Pavia P, Rapezzi C, Adler Y, et al. Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2021;42:1554-1568. doi:10.1093/eurheartj/ehab072
- Brito D, Albrecht FC, de Arenaza DP, et al. World Heart Federation consensus on transthyretin amyloidosis cardiomyopathy (ATTR-CM). Glob Heart. 2023;18:59. doi:10.5334/gh.1262
- Bodez D, Guellich A, Kharoubi M, et al. Prevalence, severity, and prognostic value of sleep apnea syndromes in cardiac amyloidosis. Sleep. 2016;39:1333-1341. doi:10.5665/sleep.5958
- Colaco B, Colaco C, Lipford M. A forgotten problem: sleep-disordered breathing in amyloidosis. Chest. 2016;150:1293A. doi:10.1016/j.chest.2016.08.1407
Transthyretin amyloid cardiomyopathy (ATTR-CM) is caused by the misfolding of the TTR protein, which results in aggregation of amyloid fibrils that deposit in the myocardium and causes restrictive cardiomyopathy. Though it remains underdiagnosed, ATTR-CM is increasingly being recognized as a cause of heart failure in geriatric patients.1 There are 2 categories of ATTRCM: wild-type ATTR-CM (wtATTR-CM), in which there is no mutation in the TTR gene, and hereditary ATTR-CM (hATTR-CM), in which a mutation is present in the TTR gene. Research has shown that wtATTR-CM accounted for as many as 30% of cases of heart failure (HF) with preserved ejection fraction (HFpEF) in patients aged > 75 years.2 A significant percentage of the veteran patient population consists of older males. Given their age, these patients are at greater risk for ATTR diagnosis.3
Identifying red flags for patients within this population may allow clinicians to make earlier diagnoses and improve outcomes. A high index of suspicion is needed to diagnose ATTR because many early signs and symptoms are extracardiac, which leads to delayed diagnoses and worse outcomes. This article describes 8 cases of ATTR-CM within the US Department of Veterans Affairs (VA) New York Harbor Healthcare System-Brooklyn (VANYHHSB).
Methods
This retrospective case series was reviewed and approved by the VANYHHSB Institutional Review Board where it was conducted. Patients diagnosed with ATTR between 2017 and 2024 were identified using International Classification of Diseases, Tenth Revision codes. Eleven patients were identified; 3 were excluded due to insufficient medical records. The remaining 8 patient records were retrospectively reviewed and included.
Case 1
A 67-year-old male with a history of carpal tunnel syndrome (CTS) presented following a syncopal episode. Initial electrocardiogram (ECG) showed sinus rhythm, first-degree atrioventricular block, and a bifascicular block. Transthoracic echocardiogram (TTE) showed moderate asymmetric left ventricular (LV) hypertrophy (LVH) and biatrial enlargement with an ejection fraction (EF) > 55%. The patient was discharged with a loop recorder and an outpatient follow-up appointment scheduled. One month later, he presented with worsening dyspnea on exertion with clinical signs of hypervolemia. A repeat TTE showed global LV wall thickening, moderately reduced LV systolic function (EF 40%), and moderate pulmonary hypertension. Given these findings, the patient underwent cardiac magnetic resonance imaging (CMR), which suggested an infiltrative cardiomyopathy. Amyloid light-chain (AL) amyloidosis evaluation, technetium-99m (99mTC) pyrophosphate imaging, and a fat pad biopsy were unrevealing. An endomyocardial biopsy was performed with electron microscopy, which confirmed amyloidosis. Genetic testing was negative, and the patient began taking tafamidis. There were no later admissions for decompensated HF; however, the patient developed atrial fibrillation (AF) and an interval TTE demonstrated no improvement in his EF. He died at age 73 years.
Case 2
A 78-year-old male with a history of CTS presented with lightheadedness. Initial ECG showed rate-controlled AF and TTE revealed a moderately thickened LV wall with normal LV size, mild left atrial enlargement, and an EF of 65%. The patient was discharged with a scheduled outpatient CMR appointment; however, he defaulted from follow-up. Two years later, he presented with recurrent syncopal episodes and physical examination was consistent with hypervolemia. Repeat TTE revealed moderate LVH, biatrial enlargement, and an EF of 55%. An inpatient CMR was suggestive of cardiac amyloidosis, and a pyrophosphate scan was diagnostic for ATTR. The patient started taking tafamidis, but continued to have recurrent admissions for HF exacerbation. He died at age 81 years.
Case 3
A 71-year-old male with a history of CTS presented with exertional dyspnea. The initial ECG showed sinus rhythm with left atrial enlargement and left axis deviation. Subsequent TTE revealed severe LVH, mildly reduced LV cavity size, moderate to severe biatrial enlargement, and an EF of 25% to 30%. Outpatient 99mTC pyrophosphate imaging suggested cardiac amyloidosis, and laboratory testing showed no evidence of monoclonal proteins. The patient was started on tafamidis for ATTR. At 2-year follow-up, he had new AF and to date has had no further hospitalizations for acute decompensated HF.
Case 4
A 92-year-old male with a history of AF and bilateral CTS presented with lightheadedness. An ECG revealed AF with a slowed ventricular response. Subsequent Holter monitoring demonstrated pauses exceeding 3 seconds, and a permanent pacemaker was recommended. During his preoperative evaluation, TTE revealed severe concentric LVH with a speckled appearance of the myocardium, mild-tomoderate biatrial enlargement, and an EF of 50% to 55%. 99mTC pyrophosphate imaging was positive for amyloidosis and the patient started taking tafamidis. Recurrent hospital admissions for decompensated HF complicated his progression. The patient died at age 95 years.
Case 5
A 72-year-old male with a history of bilateral CTS and cervical spinal stenosis presented with dyspnea on exertion. An ECG revealed a normal sinus rhythm. A TTE found severely reduced systolic function with an EF ≤ 25%, mild concentric LVH, grade 3 diastolic dysfunction, mild-tomoderate biatrial enlargement, and moderate pulmonary hypertension (Figure 1). He was started on guideline-directed medical therapy (GDMT) for HF, which included sacubitril/valsartan, metoprolol succinate, and empagliflozin. The patient’s dyspnea improved, and a workup for nonischemic cardiomyopathy was initiated. 99mTC pyrophosphate imaging 1 year after his initial presentation was positive, leading to ATTR-CM diagnosis. The patient started taking tafamidis and he has since had a stable progression and continued to demonstrate good exercise tolerance with no hospitalizations. His most recent TTE indicated an EF of 40% to 45%.
(parasternal long axis view) of patient 5
demonstrating concentric left ventricular
hypertrophy with a speckled myocardium
and dilated left atrium.
Case 6
A 76-year-old male with a history of paroxysmal AF status after multiple ablations, bilateral CTS, and severe cervical spinal stenosis presented with dyspnea on exertion. The patient’s ECG showed normal sinus rhythm and left axis deviation with concern for left anterior hemiblock. A TTE revealed moderate LVH with a speckled appearance of the myocardium and grade 3 diastolic dysfunction with preserved EF. Before completing the workup for underlying cardiomyopathy, the patient underwent an interventional radiology procedure for an angiomyolipoma, and his postoperative course was complicated by pulmonary edema, requiring admission to the coronary care unit for diuresis. A repeat TTE revealed a reduced EF of 35%, and he was discharged on GDMT. No monoclonal protein was seen in the serum or urine. The patient’s progression was complicated by recurrent admissions for acute decompensated HF and supraventricular tachycardia despite being on amiodarone, which led to a delay in obtaining 99mTC pyrophosphate imaging. Due to hypotension, the patient was unable to tolerate GDMT. He eventually underwent 99mTC pyrophosphate imaging that confirmed ATTR-CM and was started on tafamidis. One year following initial presentation, the patient’s EF progressively declined to 20% to 25%, and he died shortly after discharge to subacute rehabilitation.
Case 7
A 95-year-old male with a history of longstanding persistent AF and bilateral CTS presented with dyspnea on exertion, bendopnea, and worsening bilateral pedal edema for a week. An ECG showed AF with a controlled ventricular response and low-voltage QRS waves (Figure 2). A TTE showed biatrial enlargement, LVH, and preserved EF > 55%. He started taking furosemide and was discharged with a diagnosis of HFpEF. The patient missed cardiology follow-up and presented 1 year later with decompensated HF. An amyloidosis workup was recommended, but due to intermittent periods of being lost to follow-up, the patient did not pursue this workup until 3 years after his initial presentation when 99mTC pyrophosphate imaging confirmed ATTR-CM. The patient declined tafamidis and continued to be followed by the cardiology team. His HF is managed with furosemide as needed due to intolerance to GDMT.
demonstrating atrial fibrillation with controlled
ventricular response and low-voltage QRS.
Case 8
A 74-year-old male with history of bilateral CTS presented with right-sided chest pain associated with shortness of breath, diaphoresis, dizziness, and worsening abdominal pain. He was found to have inferior wall myocardial infarction on ECG with later percutaneous coronary intervention to the left circumflex. His hospital course was complicated by decompensated HF (EF 45% to 50%) and AF with rapid ventricular response. He was treated and discharged with follow-up visits scheduled in the cardiology clinic. Multiple attempts were made to place him on GDMT; however, the patient was unable to tolerate these medications due to recurrent admissions for syncope. During a cardiology clinic visit 3 years after his initial presentation, an amyloidosis workup was initiated. 99mTC pyrophosphate imaging was positive for ATTR-CM, and he started taking tafamidis. Before this diagnosis, ECG indicated low-voltage QRS complexes. His progression has since been complicated by admissions for decompensated HF, recurrent episodes of AF requiring atrioventricular node ablation, and biventricular implantable cardioverter-defibrillator implantation after failed attempts at electrical cardioversion. He continued to follow up in the HF clinic.
Discussion
ATTR-CM is an underdiagnosed cause of cardiomyopathy, particularly in older adults. TTR is a transport protein produced in the liver, and misfolding can occur due to age-related instability of the wild-type protein (wtATTR) or pathologic variants in the TTR (hATTR). The misfolding leads to restrictive physiology, HF (often with preserved EF) arrhythmias, and conduction system disease.1 It is likely that the predominantly older male veteran population would be predisposed to wtATTR cardiomyopathy given that misfolding in the condition is believed to be age-related.
Current criteria for ATTR diagnosis require a combination of clinical suspicion, imaging, laboratory testing, and, in some cases, tissue biopsy confirmation and genetic testing.1,4,5 The diagnostic algorithm is as follows:
Clinical suspicion. Consider ATTR in patients with unexplained HFpEF, LV wall thickness ≥ 12 to 14 mm, discordance between ECG voltage and wall thickness, or associated extracardiac manifestations such as CTS, lumbar spinal stenosis, or peripheral/ autonomic neuropathy.
Exclusion of AL amyloidosis. Bone scintigraphy alone cannot distinguish between AL amyloidosis and ATTR, so patients with suspected amyloid cardiomyopathy should undergo serum and urine immunofixation electrophoresis and serum free light chain assay to rule out a monoclonal gammopathy as seen in AL amyloidosis.
Cardiac scintigraphy. Once AL amyloidosis is excluded, a positive 99mTC-labeled boneavid tracer image (such as a pyrophosphate scan) with grade 2 or grade 3 myocardial uptake is diagnostic of ATTR.
Tissue biopsy. If there is monoclonal gammopathy or equivocal imaging, tissue biopsy (eg, endomyocardial) with Congo red staining and amyloid typing by mass spectrometry or immunohistochemistry is necessary.
Genetic testing. Once ATTR is confirmed, genetic testing distinguishes hATTR from wtATTR, which impacts management and determines the need to screen family members.
Currently, there are 3 therapies approved by the US Food and Drug Administration (FDA) to treat ATTR-CM: tafamidis, acoramidis, and vutrisiran.6-8 Tafamidis and acoramidis stabilize the TTR tetramer, preventing amyloid formation. Vutrisiran uses RNA interference to silence the gene that produces TTR. Tafamidis has been found to improve cardiovascular outcomes in ATTR-CM. In the ATTR-ACT trial, it reduced all-cause mortality and cardiovascular hospitalizations in patients with ATTR-CM and New York Heart Association class I-III symptoms.6 There are other disease-modifying therapies, such the TTR gene silencers inotersen and patisiran; however, these are only FDA-approved for hATTR polyneuropathy and not for ATTRCM; ongoing trials are evaluating their cardiac efficacy.
The mean age of ATTR-CM diagnosis in the patients described in this case series was 79 years, which is older than the mean age of 74 years reported in prior research.4 All patients were male, and the most common presenting symptom was dyspnea on exertion. Table 1 outlines baseline characteristics and associated comorbidities of patients in this case series. The patients presented with many red-flag signs of ATTR-CM (Figure 3). Among them included syncope (4 of 8 patients), spinal stenosis (2 of 8 patients), arrhythmia (7 of 8 patients), heart failure (7 of 8 patients), and bilateral CTS (all patients).
amyloidosis red-flag signs identified.
Bilateral CTS was diagnosed in all patients before their diagnosis of ATTR-CM. Patient 7 had a diagnosis of CTS 9 years before his ATTR-CM diagnosis, underscoring a subtle, yet important extracardiac sign that may increase clinical suspicion for ATTR-CM. Previous research found that the probability of having CTS is highest 5 to 9 years prior to the development of cardiomyopathy. Its presence is also a prognostic marker in ATTR, independent of cardiac involvement.9 The median interval between CTS diagnosis and cardiomyopathy diagnosis was 5 years in this series.
Although screening criteria for ATTR have been proposed, none have been incorporated into formal guidelines.10,11 We propose that a baseline ECG and screening TTE be obtained in any patient aged > 65 years with cardiac risk equivalents such as hypertension and diabetes, presenting with ≥ 1 extracardiac red-flag signs, such as bilateral CTS and spinal stenosis. This will likely facilitate an earlier diagnosis of ATTR-CM, leading to earlier treatment initiation and better patient outcomes. This initiative can be started in the primary care setting and facilitates early cardiology referral. This recommendation is based on literature supporting clinical patterns and observations the authors have made in clinical practice.
Obstructive sleep apnea (OSA) was a comorbidity present in 50% of the patients described in this case series. The literature describing this association is sparse; however, a prospective observational study reported that disorders of sleep inclusive of OSA are frequent in patients with cardiac amyloidosis.12 A theory behind this association is that amyloid deposits in the upper airway tissues lead to airway narrowing. 13 More research is needed to further assess the relationship between OSA and cardiac amyloidosis, particularly with respect to the timing of OSA prior to the development of cardiomyopathy as it may be a potential early sign for clinicians to acknowledge.
An important observation from this case series is the variability in the timing of tafamidis initiation relative to symptom onset and confirmed diagnosis of ATTR-CM (Table 2). Although tafamidis has been found to slow disease progression, several patients in this series began treatment at advanced stages or years after the onset of cardiac symptoms, potentially limiting its clinical benefit.
For example, patient 1 was diagnosed with ATTR 2 years before tafamidis became available on the market and was initially treated with diflunisal. Patients who started tafamidis earlier in the disease course (eg, patients 3 and 5) appeared to have better long-term outcomes, including an absence of heart failure hospitalizations after initiation. In contrast, patients with delayed treatment initiation (eg, patients 2, 6, and 8) experienced ongoing decompensations or early mortality. Patient 7 declined tafamidis, underscoring challenges in medication uptake among older adults. Randomized controlled trials are warranted to compare the effectiveness of tafamidis with other recently FDA-approved therapies, such as acoramidis and vutrisiran, particularly in terms of cardiovascular outcomes.
AF was the most common arrhythmia observed in these patients and may occur years before the development of HF symptoms in the setting of ATTR-CM. Due to inherent conduction system disease, AF in this population may have a controlled or slow ventricular response, as observed in patient 4. Patients with atrial fibrillation and cardiac amyloidosis should receive anticoagulation regardless of CHA2DS2- VASc score due to their high risk of intracardiac thrombus formation.4
Limitations
This case series lacked genetic testing following a confirmed ATTR-CM diagnosis. Although much of the treatment is the same regardless of the presence of a TTR mutation, knowing the specific subtype of ATTR-CM has implications for prognosis and for screening family members.
Conclusions
Following analysis of 8 patients diagnosed with ATTR, this case series could serve as a blueprint for research into ATTR in veterans. In clinical practice, following military service, veterans may not be routinely seen by an outpatient physician and may present with sequelae of advanced stages of ATTR. Early identification of red-flag symptoms can lead to a higher clinical suspicion, prompting early diagnostic evaluation and treatment initiation and ultimately mitigating adverse outcomes. Future research that includes genetic testing for those with confirmed ATTR-CM may prove useful as a foundation for detailed and informed discussions with patients and their families regarding prognosis and, if indicated, screening for family members.
Transthyretin amyloid cardiomyopathy (ATTR-CM) is caused by the misfolding of the TTR protein, which results in aggregation of amyloid fibrils that deposit in the myocardium and causes restrictive cardiomyopathy. Though it remains underdiagnosed, ATTR-CM is increasingly being recognized as a cause of heart failure in geriatric patients.1 There are 2 categories of ATTRCM: wild-type ATTR-CM (wtATTR-CM), in which there is no mutation in the TTR gene, and hereditary ATTR-CM (hATTR-CM), in which a mutation is present in the TTR gene. Research has shown that wtATTR-CM accounted for as many as 30% of cases of heart failure (HF) with preserved ejection fraction (HFpEF) in patients aged > 75 years.2 A significant percentage of the veteran patient population consists of older males. Given their age, these patients are at greater risk for ATTR diagnosis.3
Identifying red flags for patients within this population may allow clinicians to make earlier diagnoses and improve outcomes. A high index of suspicion is needed to diagnose ATTR because many early signs and symptoms are extracardiac, which leads to delayed diagnoses and worse outcomes. This article describes 8 cases of ATTR-CM within the US Department of Veterans Affairs (VA) New York Harbor Healthcare System-Brooklyn (VANYHHSB).
Methods
This retrospective case series was reviewed and approved by the VANYHHSB Institutional Review Board where it was conducted. Patients diagnosed with ATTR between 2017 and 2024 were identified using International Classification of Diseases, Tenth Revision codes. Eleven patients were identified; 3 were excluded due to insufficient medical records. The remaining 8 patient records were retrospectively reviewed and included.
Case 1
A 67-year-old male with a history of carpal tunnel syndrome (CTS) presented following a syncopal episode. Initial electrocardiogram (ECG) showed sinus rhythm, first-degree atrioventricular block, and a bifascicular block. Transthoracic echocardiogram (TTE) showed moderate asymmetric left ventricular (LV) hypertrophy (LVH) and biatrial enlargement with an ejection fraction (EF) > 55%. The patient was discharged with a loop recorder and an outpatient follow-up appointment scheduled. One month later, he presented with worsening dyspnea on exertion with clinical signs of hypervolemia. A repeat TTE showed global LV wall thickening, moderately reduced LV systolic function (EF 40%), and moderate pulmonary hypertension. Given these findings, the patient underwent cardiac magnetic resonance imaging (CMR), which suggested an infiltrative cardiomyopathy. Amyloid light-chain (AL) amyloidosis evaluation, technetium-99m (99mTC) pyrophosphate imaging, and a fat pad biopsy were unrevealing. An endomyocardial biopsy was performed with electron microscopy, which confirmed amyloidosis. Genetic testing was negative, and the patient began taking tafamidis. There were no later admissions for decompensated HF; however, the patient developed atrial fibrillation (AF) and an interval TTE demonstrated no improvement in his EF. He died at age 73 years.
Case 2
A 78-year-old male with a history of CTS presented with lightheadedness. Initial ECG showed rate-controlled AF and TTE revealed a moderately thickened LV wall with normal LV size, mild left atrial enlargement, and an EF of 65%. The patient was discharged with a scheduled outpatient CMR appointment; however, he defaulted from follow-up. Two years later, he presented with recurrent syncopal episodes and physical examination was consistent with hypervolemia. Repeat TTE revealed moderate LVH, biatrial enlargement, and an EF of 55%. An inpatient CMR was suggestive of cardiac amyloidosis, and a pyrophosphate scan was diagnostic for ATTR. The patient started taking tafamidis, but continued to have recurrent admissions for HF exacerbation. He died at age 81 years.
Case 3
A 71-year-old male with a history of CTS presented with exertional dyspnea. The initial ECG showed sinus rhythm with left atrial enlargement and left axis deviation. Subsequent TTE revealed severe LVH, mildly reduced LV cavity size, moderate to severe biatrial enlargement, and an EF of 25% to 30%. Outpatient 99mTC pyrophosphate imaging suggested cardiac amyloidosis, and laboratory testing showed no evidence of monoclonal proteins. The patient was started on tafamidis for ATTR. At 2-year follow-up, he had new AF and to date has had no further hospitalizations for acute decompensated HF.
Case 4
A 92-year-old male with a history of AF and bilateral CTS presented with lightheadedness. An ECG revealed AF with a slowed ventricular response. Subsequent Holter monitoring demonstrated pauses exceeding 3 seconds, and a permanent pacemaker was recommended. During his preoperative evaluation, TTE revealed severe concentric LVH with a speckled appearance of the myocardium, mild-tomoderate biatrial enlargement, and an EF of 50% to 55%. 99mTC pyrophosphate imaging was positive for amyloidosis and the patient started taking tafamidis. Recurrent hospital admissions for decompensated HF complicated his progression. The patient died at age 95 years.
Case 5
A 72-year-old male with a history of bilateral CTS and cervical spinal stenosis presented with dyspnea on exertion. An ECG revealed a normal sinus rhythm. A TTE found severely reduced systolic function with an EF ≤ 25%, mild concentric LVH, grade 3 diastolic dysfunction, mild-tomoderate biatrial enlargement, and moderate pulmonary hypertension (Figure 1). He was started on guideline-directed medical therapy (GDMT) for HF, which included sacubitril/valsartan, metoprolol succinate, and empagliflozin. The patient’s dyspnea improved, and a workup for nonischemic cardiomyopathy was initiated. 99mTC pyrophosphate imaging 1 year after his initial presentation was positive, leading to ATTR-CM diagnosis. The patient started taking tafamidis and he has since had a stable progression and continued to demonstrate good exercise tolerance with no hospitalizations. His most recent TTE indicated an EF of 40% to 45%.
(parasternal long axis view) of patient 5
demonstrating concentric left ventricular
hypertrophy with a speckled myocardium
and dilated left atrium.
Case 6
A 76-year-old male with a history of paroxysmal AF status after multiple ablations, bilateral CTS, and severe cervical spinal stenosis presented with dyspnea on exertion. The patient’s ECG showed normal sinus rhythm and left axis deviation with concern for left anterior hemiblock. A TTE revealed moderate LVH with a speckled appearance of the myocardium and grade 3 diastolic dysfunction with preserved EF. Before completing the workup for underlying cardiomyopathy, the patient underwent an interventional radiology procedure for an angiomyolipoma, and his postoperative course was complicated by pulmonary edema, requiring admission to the coronary care unit for diuresis. A repeat TTE revealed a reduced EF of 35%, and he was discharged on GDMT. No monoclonal protein was seen in the serum or urine. The patient’s progression was complicated by recurrent admissions for acute decompensated HF and supraventricular tachycardia despite being on amiodarone, which led to a delay in obtaining 99mTC pyrophosphate imaging. Due to hypotension, the patient was unable to tolerate GDMT. He eventually underwent 99mTC pyrophosphate imaging that confirmed ATTR-CM and was started on tafamidis. One year following initial presentation, the patient’s EF progressively declined to 20% to 25%, and he died shortly after discharge to subacute rehabilitation.
Case 7
A 95-year-old male with a history of longstanding persistent AF and bilateral CTS presented with dyspnea on exertion, bendopnea, and worsening bilateral pedal edema for a week. An ECG showed AF with a controlled ventricular response and low-voltage QRS waves (Figure 2). A TTE showed biatrial enlargement, LVH, and preserved EF > 55%. He started taking furosemide and was discharged with a diagnosis of HFpEF. The patient missed cardiology follow-up and presented 1 year later with decompensated HF. An amyloidosis workup was recommended, but due to intermittent periods of being lost to follow-up, the patient did not pursue this workup until 3 years after his initial presentation when 99mTC pyrophosphate imaging confirmed ATTR-CM. The patient declined tafamidis and continued to be followed by the cardiology team. His HF is managed with furosemide as needed due to intolerance to GDMT.
demonstrating atrial fibrillation with controlled
ventricular response and low-voltage QRS.
Case 8
A 74-year-old male with history of bilateral CTS presented with right-sided chest pain associated with shortness of breath, diaphoresis, dizziness, and worsening abdominal pain. He was found to have inferior wall myocardial infarction on ECG with later percutaneous coronary intervention to the left circumflex. His hospital course was complicated by decompensated HF (EF 45% to 50%) and AF with rapid ventricular response. He was treated and discharged with follow-up visits scheduled in the cardiology clinic. Multiple attempts were made to place him on GDMT; however, the patient was unable to tolerate these medications due to recurrent admissions for syncope. During a cardiology clinic visit 3 years after his initial presentation, an amyloidosis workup was initiated. 99mTC pyrophosphate imaging was positive for ATTR-CM, and he started taking tafamidis. Before this diagnosis, ECG indicated low-voltage QRS complexes. His progression has since been complicated by admissions for decompensated HF, recurrent episodes of AF requiring atrioventricular node ablation, and biventricular implantable cardioverter-defibrillator implantation after failed attempts at electrical cardioversion. He continued to follow up in the HF clinic.
Discussion
ATTR-CM is an underdiagnosed cause of cardiomyopathy, particularly in older adults. TTR is a transport protein produced in the liver, and misfolding can occur due to age-related instability of the wild-type protein (wtATTR) or pathologic variants in the TTR (hATTR). The misfolding leads to restrictive physiology, HF (often with preserved EF) arrhythmias, and conduction system disease.1 It is likely that the predominantly older male veteran population would be predisposed to wtATTR cardiomyopathy given that misfolding in the condition is believed to be age-related.
Current criteria for ATTR diagnosis require a combination of clinical suspicion, imaging, laboratory testing, and, in some cases, tissue biopsy confirmation and genetic testing.1,4,5 The diagnostic algorithm is as follows:
Clinical suspicion. Consider ATTR in patients with unexplained HFpEF, LV wall thickness ≥ 12 to 14 mm, discordance between ECG voltage and wall thickness, or associated extracardiac manifestations such as CTS, lumbar spinal stenosis, or peripheral/ autonomic neuropathy.
Exclusion of AL amyloidosis. Bone scintigraphy alone cannot distinguish between AL amyloidosis and ATTR, so patients with suspected amyloid cardiomyopathy should undergo serum and urine immunofixation electrophoresis and serum free light chain assay to rule out a monoclonal gammopathy as seen in AL amyloidosis.
Cardiac scintigraphy. Once AL amyloidosis is excluded, a positive 99mTC-labeled boneavid tracer image (such as a pyrophosphate scan) with grade 2 or grade 3 myocardial uptake is diagnostic of ATTR.
Tissue biopsy. If there is monoclonal gammopathy or equivocal imaging, tissue biopsy (eg, endomyocardial) with Congo red staining and amyloid typing by mass spectrometry or immunohistochemistry is necessary.
Genetic testing. Once ATTR is confirmed, genetic testing distinguishes hATTR from wtATTR, which impacts management and determines the need to screen family members.
Currently, there are 3 therapies approved by the US Food and Drug Administration (FDA) to treat ATTR-CM: tafamidis, acoramidis, and vutrisiran.6-8 Tafamidis and acoramidis stabilize the TTR tetramer, preventing amyloid formation. Vutrisiran uses RNA interference to silence the gene that produces TTR. Tafamidis has been found to improve cardiovascular outcomes in ATTR-CM. In the ATTR-ACT trial, it reduced all-cause mortality and cardiovascular hospitalizations in patients with ATTR-CM and New York Heart Association class I-III symptoms.6 There are other disease-modifying therapies, such the TTR gene silencers inotersen and patisiran; however, these are only FDA-approved for hATTR polyneuropathy and not for ATTRCM; ongoing trials are evaluating their cardiac efficacy.
The mean age of ATTR-CM diagnosis in the patients described in this case series was 79 years, which is older than the mean age of 74 years reported in prior research.4 All patients were male, and the most common presenting symptom was dyspnea on exertion. Table 1 outlines baseline characteristics and associated comorbidities of patients in this case series. The patients presented with many red-flag signs of ATTR-CM (Figure 3). Among them included syncope (4 of 8 patients), spinal stenosis (2 of 8 patients), arrhythmia (7 of 8 patients), heart failure (7 of 8 patients), and bilateral CTS (all patients).
amyloidosis red-flag signs identified.
Bilateral CTS was diagnosed in all patients before their diagnosis of ATTR-CM. Patient 7 had a diagnosis of CTS 9 years before his ATTR-CM diagnosis, underscoring a subtle, yet important extracardiac sign that may increase clinical suspicion for ATTR-CM. Previous research found that the probability of having CTS is highest 5 to 9 years prior to the development of cardiomyopathy. Its presence is also a prognostic marker in ATTR, independent of cardiac involvement.9 The median interval between CTS diagnosis and cardiomyopathy diagnosis was 5 years in this series.
Although screening criteria for ATTR have been proposed, none have been incorporated into formal guidelines.10,11 We propose that a baseline ECG and screening TTE be obtained in any patient aged > 65 years with cardiac risk equivalents such as hypertension and diabetes, presenting with ≥ 1 extracardiac red-flag signs, such as bilateral CTS and spinal stenosis. This will likely facilitate an earlier diagnosis of ATTR-CM, leading to earlier treatment initiation and better patient outcomes. This initiative can be started in the primary care setting and facilitates early cardiology referral. This recommendation is based on literature supporting clinical patterns and observations the authors have made in clinical practice.
Obstructive sleep apnea (OSA) was a comorbidity present in 50% of the patients described in this case series. The literature describing this association is sparse; however, a prospective observational study reported that disorders of sleep inclusive of OSA are frequent in patients with cardiac amyloidosis.12 A theory behind this association is that amyloid deposits in the upper airway tissues lead to airway narrowing. 13 More research is needed to further assess the relationship between OSA and cardiac amyloidosis, particularly with respect to the timing of OSA prior to the development of cardiomyopathy as it may be a potential early sign for clinicians to acknowledge.
An important observation from this case series is the variability in the timing of tafamidis initiation relative to symptom onset and confirmed diagnosis of ATTR-CM (Table 2). Although tafamidis has been found to slow disease progression, several patients in this series began treatment at advanced stages or years after the onset of cardiac symptoms, potentially limiting its clinical benefit.
For example, patient 1 was diagnosed with ATTR 2 years before tafamidis became available on the market and was initially treated with diflunisal. Patients who started tafamidis earlier in the disease course (eg, patients 3 and 5) appeared to have better long-term outcomes, including an absence of heart failure hospitalizations after initiation. In contrast, patients with delayed treatment initiation (eg, patients 2, 6, and 8) experienced ongoing decompensations or early mortality. Patient 7 declined tafamidis, underscoring challenges in medication uptake among older adults. Randomized controlled trials are warranted to compare the effectiveness of tafamidis with other recently FDA-approved therapies, such as acoramidis and vutrisiran, particularly in terms of cardiovascular outcomes.
AF was the most common arrhythmia observed in these patients and may occur years before the development of HF symptoms in the setting of ATTR-CM. Due to inherent conduction system disease, AF in this population may have a controlled or slow ventricular response, as observed in patient 4. Patients with atrial fibrillation and cardiac amyloidosis should receive anticoagulation regardless of CHA2DS2- VASc score due to their high risk of intracardiac thrombus formation.4
Limitations
This case series lacked genetic testing following a confirmed ATTR-CM diagnosis. Although much of the treatment is the same regardless of the presence of a TTR mutation, knowing the specific subtype of ATTR-CM has implications for prognosis and for screening family members.
Conclusions
Following analysis of 8 patients diagnosed with ATTR, this case series could serve as a blueprint for research into ATTR in veterans. In clinical practice, following military service, veterans may not be routinely seen by an outpatient physician and may present with sequelae of advanced stages of ATTR. Early identification of red-flag symptoms can lead to a higher clinical suspicion, prompting early diagnostic evaluation and treatment initiation and ultimately mitigating adverse outcomes. Future research that includes genetic testing for those with confirmed ATTR-CM may prove useful as a foundation for detailed and informed discussions with patients and their families regarding prognosis and, if indicated, screening for family members.
- Kittleson MM, Maurer MS, Ambardekar AV, et al. Cardiac amyloidosis: evolving diagnosis and management: a scientific statement from the American Heart Association. Circulation. 2020;142:e7-e22. doi:10.1161/CIR.0000000000000792
- Dharmarajan K, Maurer MS. Transthyretin cardiac amyloidoses in older North Americans. J Am Geriatr Soc. 2012;60:765-774. doi:10.1111/j.1532-5415.2011.03868.x
- Nativi-Nicolau J, Redd A, Kelly N, et al. Increasing number of amyloidosis diagnosis in the Veterans Affairs populations. J Card Fail. 2019;25:S96.
- Ruberg FL, Grogan M, Hanna M, et al. Transthyretin amyloid cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol. 2019;73:2872-2891. doi:10.1016/j.jacc.2019.04.003
- Gillmore JD, Maurer, Falk RH, et al. Nonbiopsy diagnosis of cardiac transthyretin amyloidosis. Circulation. 2016;133:2404-2412. doi:10.1161/CIRCULATIONAHA.116.021612
- Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy. N Engl J Med. 2018;379:1007-1016. doi:10.1056/NEJMoa1805689
- Gillmore JD, Judge DP, Cappelli F, et al. Efficacy and safety of acoramidis in transthyretin amyloid cardiomyopathy. N Engl J Med. 2024;390:132-142. doi:10.1056/NEJMoa2305434
- Fontana M, Berk JL, Gillmore JD, et al. Vutrisiran in patients with transthyretin amyloidosis with cardiomyopathy. N Engl J Med. 2025;392:33-44. doi:10.1056/NEJMoa2409134
- Milandri A, Farioli A, Gagliardi C, et al. Carpal tunnel syndrome in cardiac amyloidosis: implications for early diagnosis and prognostic role across the spectrum of aetiologies. Eur J Heart Fail. 2020;22:507-515. doi:10.1002/ejhf.1742
- Garcia-Pavia P, Rapezzi C, Adler Y, et al. Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2021;42:1554-1568. doi:10.1093/eurheartj/ehab072
- Brito D, Albrecht FC, de Arenaza DP, et al. World Heart Federation consensus on transthyretin amyloidosis cardiomyopathy (ATTR-CM). Glob Heart. 2023;18:59. doi:10.5334/gh.1262
- Bodez D, Guellich A, Kharoubi M, et al. Prevalence, severity, and prognostic value of sleep apnea syndromes in cardiac amyloidosis. Sleep. 2016;39:1333-1341. doi:10.5665/sleep.5958
- Colaco B, Colaco C, Lipford M. A forgotten problem: sleep-disordered breathing in amyloidosis. Chest. 2016;150:1293A. doi:10.1016/j.chest.2016.08.1407
- Kittleson MM, Maurer MS, Ambardekar AV, et al. Cardiac amyloidosis: evolving diagnosis and management: a scientific statement from the American Heart Association. Circulation. 2020;142:e7-e22. doi:10.1161/CIR.0000000000000792
- Dharmarajan K, Maurer MS. Transthyretin cardiac amyloidoses in older North Americans. J Am Geriatr Soc. 2012;60:765-774. doi:10.1111/j.1532-5415.2011.03868.x
- Nativi-Nicolau J, Redd A, Kelly N, et al. Increasing number of amyloidosis diagnosis in the Veterans Affairs populations. J Card Fail. 2019;25:S96.
- Ruberg FL, Grogan M, Hanna M, et al. Transthyretin amyloid cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol. 2019;73:2872-2891. doi:10.1016/j.jacc.2019.04.003
- Gillmore JD, Maurer, Falk RH, et al. Nonbiopsy diagnosis of cardiac transthyretin amyloidosis. Circulation. 2016;133:2404-2412. doi:10.1161/CIRCULATIONAHA.116.021612
- Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy. N Engl J Med. 2018;379:1007-1016. doi:10.1056/NEJMoa1805689
- Gillmore JD, Judge DP, Cappelli F, et al. Efficacy and safety of acoramidis in transthyretin amyloid cardiomyopathy. N Engl J Med. 2024;390:132-142. doi:10.1056/NEJMoa2305434
- Fontana M, Berk JL, Gillmore JD, et al. Vutrisiran in patients with transthyretin amyloidosis with cardiomyopathy. N Engl J Med. 2025;392:33-44. doi:10.1056/NEJMoa2409134
- Milandri A, Farioli A, Gagliardi C, et al. Carpal tunnel syndrome in cardiac amyloidosis: implications for early diagnosis and prognostic role across the spectrum of aetiologies. Eur J Heart Fail. 2020;22:507-515. doi:10.1002/ejhf.1742
- Garcia-Pavia P, Rapezzi C, Adler Y, et al. Diagnosis and treatment of cardiac amyloidosis: a position statement of the ESC Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2021;42:1554-1568. doi:10.1093/eurheartj/ehab072
- Brito D, Albrecht FC, de Arenaza DP, et al. World Heart Federation consensus on transthyretin amyloidosis cardiomyopathy (ATTR-CM). Glob Heart. 2023;18:59. doi:10.5334/gh.1262
- Bodez D, Guellich A, Kharoubi M, et al. Prevalence, severity, and prognostic value of sleep apnea syndromes in cardiac amyloidosis. Sleep. 2016;39:1333-1341. doi:10.5665/sleep.5958
- Colaco B, Colaco C, Lipford M. A forgotten problem: sleep-disordered breathing in amyloidosis. Chest. 2016;150:1293A. doi:10.1016/j.chest.2016.08.1407
Case Series of Patients With Cardiac Amyloidosis at VA New York Harbor Healthcare-Brooklyn
Case Series of Patients With Cardiac Amyloidosis at VA New York Harbor Healthcare-Brooklyn
Atopic Dermatitis: New Insights and Expanded Treatment Options
Atopic Dermatitis: New Insights and Expanded Treatment Options
Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.1 While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.2 The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.1 Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.3
Epidemiology
The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.1 In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.4 In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.5,6
Key Clinical Features
Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.4
Atopic dermatitis in SOC may manifest as lichenoid plaques,7 prurigo nodules,7,8 lichenification,1 and follicular accentuation.9 Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones1,8 occurring in approximately 9% of patients in one study.10
Other key clinical features of AD in patients with SOC include pityriasis alba,10 increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),1 and greater trunk and extensor involvement.1,11
Worth Noting
The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥ 3 months), tacrolimus (≥ 2 years), and pimecrolimus (≥ 2 years). Injectable options include dupilumab (≥ 6 months), lebrikizumab (≥ 12 years), nemolizumab (≥ 12 years), and tralokinumab (≥ 12 years). Oral options include abrocitinib (≥ 12 years) and upadacitinib (≥ 12 years).12 Topical options include roflumilast 0.15% cream (≥ 6 years)12 and 0.05% cream (≥ 2-5 years),13 ruxolitinib 1.5% cream (≥ 2 years),14 and tapinarof 1% cream (≥ 2 years).12
For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.7 In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”15
Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.4 Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.16
Health Disparity Highlight
In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.4 Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke17 and traffic-related air pollution.18 Low socioeconomic status and low income also have been associated with moderate16 and severe19 AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.20
In utero exposure to maternal stress is associated with AD.4 Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.18
An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.21
Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups—variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357.
- Lee HH, Patel KR, Singam V, et al. A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis. J Am Acad Dermatol. 2019;80:1526-1532.E7.
- Adawi W, Cornman H, Kambala A, et al. Diagnosing atopic dermatitis in skin of color. Dermatol Clin. 2023;41:417-429.
- Narla S, Silverberg JI. Current updates in the epidemiology and comorbidities of atopic dermatitis. Ann Allergy Asthma Immunol. 2025;135:511-520.
- Croce EA, Levy ML, Adamson AS, et al. Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations. J Allergy Clin Immunol. 2021;148:1104-1111.
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834.
- Nomura T, Wu J, Kabashima K, et al. Endophenotypic variations of atopic dermatitis by age, race, and ethnicity. J Allergy Clin Immunol. 2020;8:1840-1852.
- McColl M, Boozalis E, Aguh C, et al. Pruritus in Black skin: unique molecular characteristics and clinical features. J Natl Med Assoc. 2021;114:30-38.
- Silverberg JI, Margolis DJ, Boguniewicz M, et al. Distribution of atopic dermatitis lesions in United States adults. J Eur Acad Dermatol Venereol. 2019;33:1341-1348.
- Summey BT, Bowen SE, Allen HB. Lichen planus-like atopic dermatitis: expanding the differential diagnosis of spongiotic dermatitis. J Cutan Pathol. 2008;35:311-314.
- Odhiambo JA, Williams HC, Clayton TO, et al; ISAAC Phase Three Study Group. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-1258.E23.
- Gallagher K, Halperin-Goldstein S, Paller AS. New treatments in atopic dermatitis update. Ann Allergy Asthma Immunol. 2025;135:498-510.E10.
- Shaw ML. FDA expands roflumilast use for atopic dermatitis to children aged 2 to 5 years. Am J Managed Care. October 6, 2025. Accessed April 30, 2026. https://www.ajmc.com/view/fda-expands -roflumilast-use-for-atopic-dermatitis-to-children-aged-2-to-5-years
- Eichenfield LF, Stein Gold LF, Simpson EL, et al. Efficacy and safety of ruxolitinib cream in children aged 2 to 11 years with atopic dermatitis: results from TRuE-AD3, a phase 3, randomized double-blind study. J Am Acad of Dermatol. 2025;93:689-698.
- Heath CR, Dosono B, Shi VY, et al. Variability in skin tone changes by race and ethnicity among US adults with atopic dermatitis. Presented at: Skin of Color Update 2024, September 13-15, 2024, New York, NY.
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146.
- Narla S, Silverberg JI. The role of environmental exposures in atopic dermatitis. Curr Allergy Asthma Rep. 2020;20:74.
- Bauer SJ, Spoer BR, Ehrman R, et al. A systematic review of historic neighborhood redlining and contemporary health outcomes. Public Health. 2025;238:181-187.
- Chung J, Simpson EL. The socioeconomics of atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122:360-366.
- Martinez A, de la Rosa R, Mujahid M, et al. Structural racism and its pathways to asthma and atopic dermatitis. J Allergy Clin Immunol. 2021;148:1112-1120.
- Bell MA, Whang KA, Thomas J, et al. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: a cross-sectional study. J Natl Med Assoc. 2020;112:650-653.
Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.1 While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.2 The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.1 Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.3
Epidemiology
The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.1 In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.4 In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.5,6
Key Clinical Features
Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.4
Atopic dermatitis in SOC may manifest as lichenoid plaques,7 prurigo nodules,7,8 lichenification,1 and follicular accentuation.9 Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones1,8 occurring in approximately 9% of patients in one study.10
Other key clinical features of AD in patients with SOC include pityriasis alba,10 increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),1 and greater trunk and extensor involvement.1,11
Worth Noting
The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥ 3 months), tacrolimus (≥ 2 years), and pimecrolimus (≥ 2 years). Injectable options include dupilumab (≥ 6 months), lebrikizumab (≥ 12 years), nemolizumab (≥ 12 years), and tralokinumab (≥ 12 years). Oral options include abrocitinib (≥ 12 years) and upadacitinib (≥ 12 years).12 Topical options include roflumilast 0.15% cream (≥ 6 years)12 and 0.05% cream (≥ 2-5 years),13 ruxolitinib 1.5% cream (≥ 2 years),14 and tapinarof 1% cream (≥ 2 years).12
For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.7 In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”15
Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.4 Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.16
Health Disparity Highlight
In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.4 Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke17 and traffic-related air pollution.18 Low socioeconomic status and low income also have been associated with moderate16 and severe19 AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.20
In utero exposure to maternal stress is associated with AD.4 Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.18
An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.21
Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.
Atopic dermatitis (AD) is a chronic skin condition generally characterized by pruritic and erythematous papules and plaques.1 While AD commonly manifests in childhood, 1 in 4 patients living with AD report adult onset of the disease.2 The clinical presentation and prevalence of AD vary across age groups, skin tones, and racial and ethnic groups. Globally, AD is estimated to have a prevalence of 2.6%; however, rates vary widely by region.1 Morphology and distribution of AD lesions also vary by population; therefore, defining one classic presentation of AD is not sufficient in diverse patient populations.3
Epidemiology
The prevalence of AD ranges from 0.2% to 24.6% worldwide, with higher rates in Africa and Oceania and lower rates in India and Northern and Eastern Europe.1 In the United States, AD affects all racial and ethnic groups; however, prevalence and severity are increased in Black children compared with White children.4 In one prospective cohort study, Hispanic children and non-Hispanic Black children aged 3 years and younger had greater odds of AD persisting into mid childhood (approximately age 7 years) compared with non-Hispanic White children.5,6
Key Clinical Features
Clinical features of AD are heterogeneous and may include differences in color, morphology, and distribution. Brown, hyperpigmented, gray, and/or violaceous plaques may predominate in patients with skin of color (SOC) compared with the erythematous plaques commonly described in lighter skin tones.1,3 Established scoring systems for AD rely on erythema as a key diagnostic feature, but because erythema can be difficult to detect in darker skin tones, disease severity may be underestimated and diagnosis may be delayed in this population.4
Atopic dermatitis in SOC may manifest as lichenoid plaques,7 prurigo nodules,7,8 lichenification,1 and follicular accentuation.9 Lichen planus–like AD is a distinct variant characterized by lichenoid plaques with a predilection for the extensor surfaces and face in patients with darker skin tones1,8 occurring in approximately 9% of patients in one study.10
Other key clinical features of AD in patients with SOC include pityriasis alba,10 increased risk for postinflammatory pigment alteration (including hyperpigmentation and/or hypopigmentation),1 and greater trunk and extensor involvement.1,11
Worth Noting
The scientific landscape for AD has grown rapidly, increasing our understanding of its pathophysiology, treatment, and social impact. Nonsteroidal treatments available for pediatric and adult patients with AD have increased in recent years, including crisaborole (approved for use in those ages ≥ 3 months), tacrolimus (≥ 2 years), and pimecrolimus (≥ 2 years). Injectable options include dupilumab (≥ 6 months), lebrikizumab (≥ 12 years), nemolizumab (≥ 12 years), and tralokinumab (≥ 12 years). Oral options include abrocitinib (≥ 12 years) and upadacitinib (≥ 12 years).12 Topical options include roflumilast 0.15% cream (≥ 6 years)12 and 0.05% cream (≥ 2-5 years),13 ruxolitinib 1.5% cream (≥ 2 years),14 and tapinarof 1% cream (≥ 2 years).12
For some patients, postinflammatory pigment alteration associated with AD has a higher impact on quality of life than the AD itself.7 In a study of 260 US adults with AD, the emotional impact of pigmentary changes was greatest in Black patients, with 53.3% reporting that pigment changes bothered them “a lot” or “very much.”15
Genome-wide association studies have not identified a single determinant that explains racial and ethnic differences in susceptibility to AD.4 Instead, social determinants of health are thought to play a role in the difference in AD prevalence and severity across groups in the United States.16
Health Disparity Highlight
In an analysis of 20 US metropolitan cities, urban and inner-city residence was associated with approximately 1.7-fold increased odds of AD.4 Among pediatric patients with moderate to severe AD, Black children were more likely to be exposed to tobacco smoke17 and traffic-related air pollution.18 Low socioeconomic status and low income also have been associated with moderate16 and severe19 AD. At the same education level, Black individuals in the United States receive less income than their White counterparts and have markedly less wealth at equivalent incomes.20
In utero exposure to maternal stress is associated with AD.4 Increased IgE levels have been recorded in children who develop AD, with Black children having the highest IgE levels overall compared to other children.18
An analysis of medical records from an urban medical center in Baltimore, Maryland, from 2013 through 2018 showed that Black patients with AD were less likely to receive topical corticosteroids, topical calcineurin inhibitors, a topical phosphodiesterase 4 inhibitor, and a biologic compared to White patients with AD.21
Since the disproportionate burden experienced by patients with AD is not physiologic, it is imperative to address these systemic complexities and address the barriers impacting treatment availability to improve health outcomes for all patients living with AD.
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups—variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357.
- Lee HH, Patel KR, Singam V, et al. A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis. J Am Acad Dermatol. 2019;80:1526-1532.E7.
- Adawi W, Cornman H, Kambala A, et al. Diagnosing atopic dermatitis in skin of color. Dermatol Clin. 2023;41:417-429.
- Narla S, Silverberg JI. Current updates in the epidemiology and comorbidities of atopic dermatitis. Ann Allergy Asthma Immunol. 2025;135:511-520.
- Croce EA, Levy ML, Adamson AS, et al. Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations. J Allergy Clin Immunol. 2021;148:1104-1111.
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834.
- Nomura T, Wu J, Kabashima K, et al. Endophenotypic variations of atopic dermatitis by age, race, and ethnicity. J Allergy Clin Immunol. 2020;8:1840-1852.
- McColl M, Boozalis E, Aguh C, et al. Pruritus in Black skin: unique molecular characteristics and clinical features. J Natl Med Assoc. 2021;114:30-38.
- Silverberg JI, Margolis DJ, Boguniewicz M, et al. Distribution of atopic dermatitis lesions in United States adults. J Eur Acad Dermatol Venereol. 2019;33:1341-1348.
- Summey BT, Bowen SE, Allen HB. Lichen planus-like atopic dermatitis: expanding the differential diagnosis of spongiotic dermatitis. J Cutan Pathol. 2008;35:311-314.
- Odhiambo JA, Williams HC, Clayton TO, et al; ISAAC Phase Three Study Group. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-1258.E23.
- Gallagher K, Halperin-Goldstein S, Paller AS. New treatments in atopic dermatitis update. Ann Allergy Asthma Immunol. 2025;135:498-510.E10.
- Shaw ML. FDA expands roflumilast use for atopic dermatitis to children aged 2 to 5 years. Am J Managed Care. October 6, 2025. Accessed April 30, 2026. https://www.ajmc.com/view/fda-expands -roflumilast-use-for-atopic-dermatitis-to-children-aged-2-to-5-years
- Eichenfield LF, Stein Gold LF, Simpson EL, et al. Efficacy and safety of ruxolitinib cream in children aged 2 to 11 years with atopic dermatitis: results from TRuE-AD3, a phase 3, randomized double-blind study. J Am Acad of Dermatol. 2025;93:689-698.
- Heath CR, Dosono B, Shi VY, et al. Variability in skin tone changes by race and ethnicity among US adults with atopic dermatitis. Presented at: Skin of Color Update 2024, September 13-15, 2024, New York, NY.
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146.
- Narla S, Silverberg JI. The role of environmental exposures in atopic dermatitis. Curr Allergy Asthma Rep. 2020;20:74.
- Bauer SJ, Spoer BR, Ehrman R, et al. A systematic review of historic neighborhood redlining and contemporary health outcomes. Public Health. 2025;238:181-187.
- Chung J, Simpson EL. The socioeconomics of atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122:360-366.
- Martinez A, de la Rosa R, Mujahid M, et al. Structural racism and its pathways to asthma and atopic dermatitis. J Allergy Clin Immunol. 2021;148:1112-1120.
- Bell MA, Whang KA, Thomas J, et al. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: a cross-sectional study. J Natl Med Assoc. 2020;112:650-653.
- Kaufman BP, Guttman-Yassky E, Alexis AF. Atopic dermatitis in diverse racial and ethnic groups—variations in epidemiology, genetics, clinical presentation and treatment. Exp Dermatol. 2018;27:340-357.
- Lee HH, Patel KR, Singam V, et al. A systematic review and meta-analysis of the prevalence and phenotype of adult-onset atopic dermatitis. J Am Acad Dermatol. 2019;80:1526-1532.E7.
- Adawi W, Cornman H, Kambala A, et al. Diagnosing atopic dermatitis in skin of color. Dermatol Clin. 2023;41:417-429.
- Narla S, Silverberg JI. Current updates in the epidemiology and comorbidities of atopic dermatitis. Ann Allergy Asthma Immunol. 2025;135:511-520.
- Croce EA, Levy ML, Adamson AS, et al. Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations. J Allergy Clin Immunol. 2021;148:1104-1111.
- Kim Y, Blomberg M, Rifas-Shiman SL, et al. Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis. J Invest Dermatol. 2019;139:827-834.
- Nomura T, Wu J, Kabashima K, et al. Endophenotypic variations of atopic dermatitis by age, race, and ethnicity. J Allergy Clin Immunol. 2020;8:1840-1852.
- McColl M, Boozalis E, Aguh C, et al. Pruritus in Black skin: unique molecular characteristics and clinical features. J Natl Med Assoc. 2021;114:30-38.
- Silverberg JI, Margolis DJ, Boguniewicz M, et al. Distribution of atopic dermatitis lesions in United States adults. J Eur Acad Dermatol Venereol. 2019;33:1341-1348.
- Summey BT, Bowen SE, Allen HB. Lichen planus-like atopic dermatitis: expanding the differential diagnosis of spongiotic dermatitis. J Cutan Pathol. 2008;35:311-314.
- Odhiambo JA, Williams HC, Clayton TO, et al; ISAAC Phase Three Study Group. Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three. J Allergy Clin Immunol. 2009;124:1251-1258.E23.
- Gallagher K, Halperin-Goldstein S, Paller AS. New treatments in atopic dermatitis update. Ann Allergy Asthma Immunol. 2025;135:498-510.E10.
- Shaw ML. FDA expands roflumilast use for atopic dermatitis to children aged 2 to 5 years. Am J Managed Care. October 6, 2025. Accessed April 30, 2026. https://www.ajmc.com/view/fda-expands -roflumilast-use-for-atopic-dermatitis-to-children-aged-2-to-5-years
- Eichenfield LF, Stein Gold LF, Simpson EL, et al. Efficacy and safety of ruxolitinib cream in children aged 2 to 11 years with atopic dermatitis: results from TRuE-AD3, a phase 3, randomized double-blind study. J Am Acad of Dermatol. 2025;93:689-698.
- Heath CR, Dosono B, Shi VY, et al. Variability in skin tone changes by race and ethnicity among US adults with atopic dermatitis. Presented at: Skin of Color Update 2024, September 13-15, 2024, New York, NY.
- Tackett KJ, Jenkins F, Morrell DS, et al. Structural racism and its influence on the severity of atopic dermatitis in African American children. Pediatr Dermatol. 2020;37:142-146.
- Narla S, Silverberg JI. The role of environmental exposures in atopic dermatitis. Curr Allergy Asthma Rep. 2020;20:74.
- Bauer SJ, Spoer BR, Ehrman R, et al. A systematic review of historic neighborhood redlining and contemporary health outcomes. Public Health. 2025;238:181-187.
- Chung J, Simpson EL. The socioeconomics of atopic dermatitis. Ann Allergy Asthma Immunol. 2019;122:360-366.
- Martinez A, de la Rosa R, Mujahid M, et al. Structural racism and its pathways to asthma and atopic dermatitis. J Allergy Clin Immunol. 2021;148:1112-1120.
- Bell MA, Whang KA, Thomas J, et al. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: a cross-sectional study. J Natl Med Assoc. 2020;112:650-653.
Atopic Dermatitis: New Insights and Expanded Treatment Options
Atopic Dermatitis: New Insights and Expanded Treatment Options
VA Advanced Training for Clinician Researchers and Data Scientists in Mental Health
VA Advanced Training for Clinician Researchers and Data Scientists in Mental Health
The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”1 Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.
Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.4 The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.
Advanced Fellows Program
The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.5 Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.
In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.
Fellowship Structure
The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.
The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.
This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.
AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.6
VA Advanced Fellowships Successes
From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.
employment across all settings, July 2020 to June 2025.
The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.
Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.
Conclusions
The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.
- US Department of Veterans Affairs. Our VA mission and core values. Updated April 17, 2025. Accessed March 2, 2026. https://department.va.gov/icare/
- Holliday R, Holder N. VA is a leader in mental health and social service research and operations. Fed Pract. 2025;42:S5. doi:10.12788/fp.0578
- Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. J Clin Psychol Med Settings. 2008;15:73-78. doi:10.1007/s10880-008-9100-4
- O’Hara R, Cassidy-Eagle EL, Beaudreau SA, et al. Increasing the ranks of academic researchers in mental health: a multisite approach to postdoctoral fellowship training. Acad Med. 2010;85:41-47. doi:10.1097/ACM.0b013e3181c47c51
- US Department of Veterans Affairs. Office of Academic Affiliations. Updated March 13, 2025. Accessed March 2, 2026. https://www.va.gov/oaa/advancedfellowships /advanced-fellowships.asp
- Hantke NC, Samarina V, Hallmayer J, et al. Preparing the next generation of academic researchers during the pandemic: lessons from a national mental health research postdoctoral fellowship. Acad Psychiatry. 2022;46:466- 469. doi:10.1007/s40596-022-01613-4
The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”1 Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.
Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.4 The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.
Advanced Fellows Program
The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.5 Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.
In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.
Fellowship Structure
The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.
The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.
This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.
AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.6
VA Advanced Fellowships Successes
From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.
employment across all settings, July 2020 to June 2025.
The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.
Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.
Conclusions
The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.
The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”1 Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.
Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.4 The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.
Advanced Fellows Program
The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.5 Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.
In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.
Fellowship Structure
The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.
The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.
This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.
AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.6
VA Advanced Fellowships Successes
From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.
employment across all settings, July 2020 to June 2025.
The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.
Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.
Conclusions
The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.
- US Department of Veterans Affairs. Our VA mission and core values. Updated April 17, 2025. Accessed March 2, 2026. https://department.va.gov/icare/
- Holliday R, Holder N. VA is a leader in mental health and social service research and operations. Fed Pract. 2025;42:S5. doi:10.12788/fp.0578
- Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. J Clin Psychol Med Settings. 2008;15:73-78. doi:10.1007/s10880-008-9100-4
- O’Hara R, Cassidy-Eagle EL, Beaudreau SA, et al. Increasing the ranks of academic researchers in mental health: a multisite approach to postdoctoral fellowship training. Acad Med. 2010;85:41-47. doi:10.1097/ACM.0b013e3181c47c51
- US Department of Veterans Affairs. Office of Academic Affiliations. Updated March 13, 2025. Accessed March 2, 2026. https://www.va.gov/oaa/advancedfellowships /advanced-fellowships.asp
- Hantke NC, Samarina V, Hallmayer J, et al. Preparing the next generation of academic researchers during the pandemic: lessons from a national mental health research postdoctoral fellowship. Acad Psychiatry. 2022;46:466- 469. doi:10.1007/s40596-022-01613-4
- US Department of Veterans Affairs. Our VA mission and core values. Updated April 17, 2025. Accessed March 2, 2026. https://department.va.gov/icare/
- Holliday R, Holder N. VA is a leader in mental health and social service research and operations. Fed Pract. 2025;42:S5. doi:10.12788/fp.0578
- Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. J Clin Psychol Med Settings. 2008;15:73-78. doi:10.1007/s10880-008-9100-4
- O’Hara R, Cassidy-Eagle EL, Beaudreau SA, et al. Increasing the ranks of academic researchers in mental health: a multisite approach to postdoctoral fellowship training. Acad Med. 2010;85:41-47. doi:10.1097/ACM.0b013e3181c47c51
- US Department of Veterans Affairs. Office of Academic Affiliations. Updated March 13, 2025. Accessed March 2, 2026. https://www.va.gov/oaa/advancedfellowships /advanced-fellowships.asp
- Hantke NC, Samarina V, Hallmayer J, et al. Preparing the next generation of academic researchers during the pandemic: lessons from a national mental health research postdoctoral fellowship. Acad Psychiatry. 2022;46:466- 469. doi:10.1007/s40596-022-01613-4
VA Advanced Training for Clinician Researchers and Data Scientists in Mental Health
VA Advanced Training for Clinician Researchers and Data Scientists in Mental Health
The Home Improvements and Structural Alterations Program: Overview and Future Implications
The Home Improvements and Structural Alterations Program: Overview and Future Implications
The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.2-8
The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.
Methods
Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.
Interview Process
Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.
Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.
This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.
Results
Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.
PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.
In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.
Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.9 Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.1,2
Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.1 The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.
To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.
The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.
The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.
Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.
Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.
Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.
Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.
Future Directions
Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.
Conclusions
A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.
- Semeah LM, Ahrentzen S, Jia H, et al. The Home Improvements and Structural Alterations Benefits Program: veterans with disabilities and home accessibility. J Disabil Policy Stud. 2017;28:43-51. doi:10.1177/1044207317696275
- Semeah LM, Wang X, Cowper Ripley DC, et al. Improving health through a home modification service for veterans. In: Fiedler BA, ed. Three Facets of Public Health and Paths to Improvements. 2020:381-416. doi:10.1016/B978-0-12-819008-1.00014-6
- Semeah LM, Ganesh SP, Wang X, et al. Home modification and health services utilization by rural and urban veterans with disabilities. Housing Policy Debate. 2021;31:862-874. doi:10.1080/10511482.2020.1858923
- Semeah LM, Orozco T, Wang X, et al. Home modifications for rural veterans with disabilities. Fed Pract. 2021;38:300- 310. doi:10.12788/fp.0153
- Semeah LM, Orozco T, Wang X, et al. Predictors of countylevel home modification use across the US. Fed Pract. 2022;39:274-280. doi:10.12788/fp.0279
- Semeah LM, Orozco T, Wang X, et al. Rural and urban home modification program users: a comparative study. HERD. 2023;16:223-235. doi:10.1177/19375867221142627
- US Department of of Veterans Affairs. Home Improvements and Structural Alterations (HISA) benefits program: final rule. Fed Regist. 2014;79:71658-71663
- US Department of Veterans Affairs. Home Improvement and Structural Alterations (HISA): increase in the limit for home improvement and structural alterations (HISA)-VA: final regulations. Fed Regist. 1993;58:25565.
- US Department of Veterans Affairs. Eligibility for VA disability benefits. Updated April 25, 2025. Accessed April 1, 2026. https://www.va.gov/disability/eligibility
The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.2-8
The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.
Methods
Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.
Interview Process
Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.
Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.
This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.
Results
Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.
PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.
In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.
Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.9 Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.1,2
Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.1 The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.
To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.
The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.
The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.
Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.
Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.
Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.
Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.
Future Directions
Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.
Conclusions
A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.
The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.2-8
The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.
Methods
Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.
Interview Process
Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.
Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.
This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.
Results
Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.
PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.
In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.
Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.9 Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.1,2
Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.1 The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.
To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.
The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.
The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.
Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.
Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.
Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.
Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.
Future Directions
Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.
Conclusions
A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.
- Semeah LM, Ahrentzen S, Jia H, et al. The Home Improvements and Structural Alterations Benefits Program: veterans with disabilities and home accessibility. J Disabil Policy Stud. 2017;28:43-51. doi:10.1177/1044207317696275
- Semeah LM, Wang X, Cowper Ripley DC, et al. Improving health through a home modification service for veterans. In: Fiedler BA, ed. Three Facets of Public Health and Paths to Improvements. 2020:381-416. doi:10.1016/B978-0-12-819008-1.00014-6
- Semeah LM, Ganesh SP, Wang X, et al. Home modification and health services utilization by rural and urban veterans with disabilities. Housing Policy Debate. 2021;31:862-874. doi:10.1080/10511482.2020.1858923
- Semeah LM, Orozco T, Wang X, et al. Home modifications for rural veterans with disabilities. Fed Pract. 2021;38:300- 310. doi:10.12788/fp.0153
- Semeah LM, Orozco T, Wang X, et al. Predictors of countylevel home modification use across the US. Fed Pract. 2022;39:274-280. doi:10.12788/fp.0279
- Semeah LM, Orozco T, Wang X, et al. Rural and urban home modification program users: a comparative study. HERD. 2023;16:223-235. doi:10.1177/19375867221142627
- US Department of of Veterans Affairs. Home Improvements and Structural Alterations (HISA) benefits program: final rule. Fed Regist. 2014;79:71658-71663
- US Department of Veterans Affairs. Home Improvement and Structural Alterations (HISA): increase in the limit for home improvement and structural alterations (HISA)-VA: final regulations. Fed Regist. 1993;58:25565.
- US Department of Veterans Affairs. Eligibility for VA disability benefits. Updated April 25, 2025. Accessed April 1, 2026. https://www.va.gov/disability/eligibility
- Semeah LM, Ahrentzen S, Jia H, et al. The Home Improvements and Structural Alterations Benefits Program: veterans with disabilities and home accessibility. J Disabil Policy Stud. 2017;28:43-51. doi:10.1177/1044207317696275
- Semeah LM, Wang X, Cowper Ripley DC, et al. Improving health through a home modification service for veterans. In: Fiedler BA, ed. Three Facets of Public Health and Paths to Improvements. 2020:381-416. doi:10.1016/B978-0-12-819008-1.00014-6
- Semeah LM, Ganesh SP, Wang X, et al. Home modification and health services utilization by rural and urban veterans with disabilities. Housing Policy Debate. 2021;31:862-874. doi:10.1080/10511482.2020.1858923
- Semeah LM, Orozco T, Wang X, et al. Home modifications for rural veterans with disabilities. Fed Pract. 2021;38:300- 310. doi:10.12788/fp.0153
- Semeah LM, Orozco T, Wang X, et al. Predictors of countylevel home modification use across the US. Fed Pract. 2022;39:274-280. doi:10.12788/fp.0279
- Semeah LM, Orozco T, Wang X, et al. Rural and urban home modification program users: a comparative study. HERD. 2023;16:223-235. doi:10.1177/19375867221142627
- US Department of of Veterans Affairs. Home Improvements and Structural Alterations (HISA) benefits program: final rule. Fed Regist. 2014;79:71658-71663
- US Department of Veterans Affairs. Home Improvement and Structural Alterations (HISA): increase in the limit for home improvement and structural alterations (HISA)-VA: final regulations. Fed Regist. 1993;58:25565.
- US Department of Veterans Affairs. Eligibility for VA disability benefits. Updated April 25, 2025. Accessed April 1, 2026. https://www.va.gov/disability/eligibility
The Home Improvements and Structural Alterations Program: Overview and Future Implications
The Home Improvements and Structural Alterations Program: Overview and Future Implications
The Development of a Comprehensive Wound Care Fellowship Curriculum
The Development of a Comprehensive Wound Care Fellowship Curriculum
Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.1-3 In 2023, estimated US wound care costs were $126.86 billion.4 About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.5 Associated costs of chronic wounds are expected to increase as the populations of developed countries age.6 Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.7,8
The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.8 Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.5
One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.11 Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).
This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.
Program Development
The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.12,13
Scoping Review
A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). 12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),15 an international wound specialist professional society (European Union of Medical Specialists), 16 and recommended curriculum guidelines for wound care residency programs.17 ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,18 plastic surgery,19 dermatology, 20 foot and ankle,21 orthopedic surgery,22 spinal cord injury,23 and geriatric medicine.24
The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.
Training Program Feedback
We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.25 Suggestions for structured, advanced didactics are in Table 2.
Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.
The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.
Discussion
An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.
Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.
Conclusions
As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.
- Fife CE, Eckert KA, Carter MJ. Publicly Reported wound healing rates: the fantasy and the reality. Adv Wound Care (New Rochelle). 2018;7:77-94. doi:10.1089/wound.2017.0743
- Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care?. Wound Repair Regen. 2010;18:154-158. doi:10.1111/j.1524-475X.2010.00571.x
- Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17:763-771. doi:10.1111/j.1524-475X.2009.00543.x
- Queen D, Harding K. What’s the true costs of wounds faced by different healthcare systems around the world?. Int Wound J. 2023;20:3935-3938. doi:10.1111/iwj.14491
- Greer N, Foman N, Dorrian J, et al. Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial Ulcers: A Systematic Review [Internet]. US Dept of Veterans Affairs; November 2012. https://www.ncbi.nlm.nih.gov/books/NBK132238/
- Simman R, McNevin AJ. Pursuing the path to specialized wound care: the ABWMS perspective. Todays Wound Clin. 2017;8:10,12.
- Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence in intensive care patients: a cross-sectional study. J Eval Clin Pract. 2008;14:563-568. doi:10.1111/j.1365-2753.2007.00918.x
- Ennis WJ, Valdes W, Meneses P. Wound care specialization: a proposal for a comprehensive fellowship program. Wound Repair Regen. 2004;12:120-128. doi:10.1111/j.1067-1927.2004.012203.x
- Patel NP, Granick MS. Wound education: American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59:53-55. doi:10.1097/SAP.0b013e31802dd43b
- Patel NP, Granick MS, Kanakaris NK, et al. Comparison of wound education in medical schools in the United States, United Kingdom, and Germany. Eplasty. 2008;8:e8.
- Ennis WJ. Wound care specialization: the current status and future plans to move wound care into the medical community. Adv Wound Care (New Rochelle). 2012;1:184- 188. doi:10.1089/wound.2011.0346
- Accreditation Council for Graduate Medical Education. ACGME common program requirements (fellowship). Updated September 3, 2025. Accessed January 15, 2026. https://www.acgme.org/globalassets/pfassets /programrequirements/2025-reformatted-requirements/cprfellowship_2025_reformatted.pdf
- Accreditation Council for Graduate Medical Education. Program directors’ guide to the common program requirements (fellowship). Updated December 2025. Accessed May 27, 2026. https://www .acgme.org/globalassets/pdfs/guide-to-the-common -program-requirements-fellowship.pdf
- Curriculum overview - wound care and hyperbaric medicine fellowship. Wake Forest University School of Medicine. 2026. Accessed January 5, 2026. https://school .wakehealth.edu/Education-and-Training/Residencies -and-Fellowships/Wound-Care-and-Hyperbaric-Medicine -Fellowship/Curriculum-Overview
- Curriculum overview - American Board of Wound Medicine and Surgery. Core Curriculum for Fellowships in Wound Care. American Board of Wound Medicine and Surgery. 2022. Accessed January 5, 2026. https://abwms.org /curriculum-overview/
- European Wound Management Association. EWMA Wound healing curriculum for physicians. February 13, 2017. Accessed January 15, 2026. https://ewma.org /wp-content/uploads/2024/02/ETR-TF-Wound-Healing -UEMS-approved.pdf
- Accreditation Council for Graduate Medical Education. Recommended Curriculum Guidelines for Family Medicine Residents. Accessed January 5, 2026. https://www.aafp .org/dam/AAFP/documents/medical_education_residency /program_directors/Wound_Care.pdf
- Accreditation Council for Graduate Medical Education. Vascular Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /VascularSurgeryMilestones2.0.pdf
- Accreditation Council for Graduate Medical Education. Plastic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/PlasticSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Dermatology Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /DermatologyMilestones.pdf
- Accreditation Council for Graduate Medical Education. The Foot and Ankle Milestone Project a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. July 2015. Accessed January 5, 2026. https://www.acgme.org /Portals/0/PDFs/Milestones/FootandAnkleMilestones.pdf
- Accreditation Council for Graduate Medical Education. Orthopaedic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /OrthopaedicSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Spinal Cord Injury Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/SpinalCordInjuryMedicineMilestones.pdf
- Accreditation Council for Graduate Medical Education. Geriatric Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /GeriatricMedicineMilestones.pdf
- Goldhamer ME, Baker K, Anne Rigg DW, et al. Development and implementation of multi-source assessment tools for ACGME residents and fellows. MedEDPORTAL. 2014. Accessed May 14, 2026. doi:10.15766/mep_2374-8265.9839
Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.1-3 In 2023, estimated US wound care costs were $126.86 billion.4 About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.5 Associated costs of chronic wounds are expected to increase as the populations of developed countries age.6 Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.7,8
The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.8 Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.5
One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.11 Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).
This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.
Program Development
The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.12,13
Scoping Review
A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). 12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),15 an international wound specialist professional society (European Union of Medical Specialists), 16 and recommended curriculum guidelines for wound care residency programs.17 ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,18 plastic surgery,19 dermatology, 20 foot and ankle,21 orthopedic surgery,22 spinal cord injury,23 and geriatric medicine.24
The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.
Training Program Feedback
We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.25 Suggestions for structured, advanced didactics are in Table 2.
Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.
The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.
Discussion
An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.
Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.
Conclusions
As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.
Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.1-3 In 2023, estimated US wound care costs were $126.86 billion.4 About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.5 Associated costs of chronic wounds are expected to increase as the populations of developed countries age.6 Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.7,8
The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.8 Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.5
One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.11 Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).
This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.
Program Development
The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.12,13
Scoping Review
A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). 12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),15 an international wound specialist professional society (European Union of Medical Specialists), 16 and recommended curriculum guidelines for wound care residency programs.17 ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,18 plastic surgery,19 dermatology, 20 foot and ankle,21 orthopedic surgery,22 spinal cord injury,23 and geriatric medicine.24
The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.
Training Program Feedback
We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.25 Suggestions for structured, advanced didactics are in Table 2.
Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.
The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.
Discussion
An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.
Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.
Conclusions
As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.
- Fife CE, Eckert KA, Carter MJ. Publicly Reported wound healing rates: the fantasy and the reality. Adv Wound Care (New Rochelle). 2018;7:77-94. doi:10.1089/wound.2017.0743
- Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care?. Wound Repair Regen. 2010;18:154-158. doi:10.1111/j.1524-475X.2010.00571.x
- Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17:763-771. doi:10.1111/j.1524-475X.2009.00543.x
- Queen D, Harding K. What’s the true costs of wounds faced by different healthcare systems around the world?. Int Wound J. 2023;20:3935-3938. doi:10.1111/iwj.14491
- Greer N, Foman N, Dorrian J, et al. Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial Ulcers: A Systematic Review [Internet]. US Dept of Veterans Affairs; November 2012. https://www.ncbi.nlm.nih.gov/books/NBK132238/
- Simman R, McNevin AJ. Pursuing the path to specialized wound care: the ABWMS perspective. Todays Wound Clin. 2017;8:10,12.
- Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence in intensive care patients: a cross-sectional study. J Eval Clin Pract. 2008;14:563-568. doi:10.1111/j.1365-2753.2007.00918.x
- Ennis WJ, Valdes W, Meneses P. Wound care specialization: a proposal for a comprehensive fellowship program. Wound Repair Regen. 2004;12:120-128. doi:10.1111/j.1067-1927.2004.012203.x
- Patel NP, Granick MS. Wound education: American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59:53-55. doi:10.1097/SAP.0b013e31802dd43b
- Patel NP, Granick MS, Kanakaris NK, et al. Comparison of wound education in medical schools in the United States, United Kingdom, and Germany. Eplasty. 2008;8:e8.
- Ennis WJ. Wound care specialization: the current status and future plans to move wound care into the medical community. Adv Wound Care (New Rochelle). 2012;1:184- 188. doi:10.1089/wound.2011.0346
- Accreditation Council for Graduate Medical Education. ACGME common program requirements (fellowship). Updated September 3, 2025. Accessed January 15, 2026. https://www.acgme.org/globalassets/pfassets /programrequirements/2025-reformatted-requirements/cprfellowship_2025_reformatted.pdf
- Accreditation Council for Graduate Medical Education. Program directors’ guide to the common program requirements (fellowship). Updated December 2025. Accessed May 27, 2026. https://www .acgme.org/globalassets/pdfs/guide-to-the-common -program-requirements-fellowship.pdf
- Curriculum overview - wound care and hyperbaric medicine fellowship. Wake Forest University School of Medicine. 2026. Accessed January 5, 2026. https://school .wakehealth.edu/Education-and-Training/Residencies -and-Fellowships/Wound-Care-and-Hyperbaric-Medicine -Fellowship/Curriculum-Overview
- Curriculum overview - American Board of Wound Medicine and Surgery. Core Curriculum for Fellowships in Wound Care. American Board of Wound Medicine and Surgery. 2022. Accessed January 5, 2026. https://abwms.org /curriculum-overview/
- European Wound Management Association. EWMA Wound healing curriculum for physicians. February 13, 2017. Accessed January 15, 2026. https://ewma.org /wp-content/uploads/2024/02/ETR-TF-Wound-Healing -UEMS-approved.pdf
- Accreditation Council for Graduate Medical Education. Recommended Curriculum Guidelines for Family Medicine Residents. Accessed January 5, 2026. https://www.aafp .org/dam/AAFP/documents/medical_education_residency /program_directors/Wound_Care.pdf
- Accreditation Council for Graduate Medical Education. Vascular Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /VascularSurgeryMilestones2.0.pdf
- Accreditation Council for Graduate Medical Education. Plastic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/PlasticSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Dermatology Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /DermatologyMilestones.pdf
- Accreditation Council for Graduate Medical Education. The Foot and Ankle Milestone Project a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. July 2015. Accessed January 5, 2026. https://www.acgme.org /Portals/0/PDFs/Milestones/FootandAnkleMilestones.pdf
- Accreditation Council for Graduate Medical Education. Orthopaedic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /OrthopaedicSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Spinal Cord Injury Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/SpinalCordInjuryMedicineMilestones.pdf
- Accreditation Council for Graduate Medical Education. Geriatric Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /GeriatricMedicineMilestones.pdf
- Goldhamer ME, Baker K, Anne Rigg DW, et al. Development and implementation of multi-source assessment tools for ACGME residents and fellows. MedEDPORTAL. 2014. Accessed May 14, 2026. doi:10.15766/mep_2374-8265.9839
- Fife CE, Eckert KA, Carter MJ. Publicly Reported wound healing rates: the fantasy and the reality. Adv Wound Care (New Rochelle). 2018;7:77-94. doi:10.1089/wound.2017.0743
- Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care?. Wound Repair Regen. 2010;18:154-158. doi:10.1111/j.1524-475X.2010.00571.x
- Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17:763-771. doi:10.1111/j.1524-475X.2009.00543.x
- Queen D, Harding K. What’s the true costs of wounds faced by different healthcare systems around the world?. Int Wound J. 2023;20:3935-3938. doi:10.1111/iwj.14491
- Greer N, Foman N, Dorrian J, et al. Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial Ulcers: A Systematic Review [Internet]. US Dept of Veterans Affairs; November 2012. https://www.ncbi.nlm.nih.gov/books/NBK132238/
- Simman R, McNevin AJ. Pursuing the path to specialized wound care: the ABWMS perspective. Todays Wound Clin. 2017;8:10,12.
- Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence in intensive care patients: a cross-sectional study. J Eval Clin Pract. 2008;14:563-568. doi:10.1111/j.1365-2753.2007.00918.x
- Ennis WJ, Valdes W, Meneses P. Wound care specialization: a proposal for a comprehensive fellowship program. Wound Repair Regen. 2004;12:120-128. doi:10.1111/j.1067-1927.2004.012203.x
- Patel NP, Granick MS. Wound education: American medical students are inadequately trained in wound care. Ann Plast Surg. 2007;59:53-55. doi:10.1097/SAP.0b013e31802dd43b
- Patel NP, Granick MS, Kanakaris NK, et al. Comparison of wound education in medical schools in the United States, United Kingdom, and Germany. Eplasty. 2008;8:e8.
- Ennis WJ. Wound care specialization: the current status and future plans to move wound care into the medical community. Adv Wound Care (New Rochelle). 2012;1:184- 188. doi:10.1089/wound.2011.0346
- Accreditation Council for Graduate Medical Education. ACGME common program requirements (fellowship). Updated September 3, 2025. Accessed January 15, 2026. https://www.acgme.org/globalassets/pfassets /programrequirements/2025-reformatted-requirements/cprfellowship_2025_reformatted.pdf
- Accreditation Council for Graduate Medical Education. Program directors’ guide to the common program requirements (fellowship). Updated December 2025. Accessed May 27, 2026. https://www .acgme.org/globalassets/pdfs/guide-to-the-common -program-requirements-fellowship.pdf
- Curriculum overview - wound care and hyperbaric medicine fellowship. Wake Forest University School of Medicine. 2026. Accessed January 5, 2026. https://school .wakehealth.edu/Education-and-Training/Residencies -and-Fellowships/Wound-Care-and-Hyperbaric-Medicine -Fellowship/Curriculum-Overview
- Curriculum overview - American Board of Wound Medicine and Surgery. Core Curriculum for Fellowships in Wound Care. American Board of Wound Medicine and Surgery. 2022. Accessed January 5, 2026. https://abwms.org /curriculum-overview/
- European Wound Management Association. EWMA Wound healing curriculum for physicians. February 13, 2017. Accessed January 15, 2026. https://ewma.org /wp-content/uploads/2024/02/ETR-TF-Wound-Healing -UEMS-approved.pdf
- Accreditation Council for Graduate Medical Education. Recommended Curriculum Guidelines for Family Medicine Residents. Accessed January 5, 2026. https://www.aafp .org/dam/AAFP/documents/medical_education_residency /program_directors/Wound_Care.pdf
- Accreditation Council for Graduate Medical Education. Vascular Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /VascularSurgeryMilestones2.0.pdf
- Accreditation Council for Graduate Medical Education. Plastic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/PlasticSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Dermatology Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /DermatologyMilestones.pdf
- Accreditation Council for Graduate Medical Education. The Foot and Ankle Milestone Project a joint initiative of the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. July 2015. Accessed January 5, 2026. https://www.acgme.org /Portals/0/PDFs/Milestones/FootandAnkleMilestones.pdf
- Accreditation Council for Graduate Medical Education. Orthopaedic Surgery Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /OrthopaedicSurgeryMilestones.pdf
- Accreditation Council for Graduate Medical Education. Spinal Cord Injury Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs /Milestones/SpinalCordInjuryMedicineMilestones.pdf
- Accreditation Council for Graduate Medical Education. Geriatric Medicine Milestones the Accreditation Council for Graduate Medical Education. Accessed January 5, 2026. https://www.acgme.org/Portals/0/PDFs/Milestones /GeriatricMedicineMilestones.pdf
- Goldhamer ME, Baker K, Anne Rigg DW, et al. Development and implementation of multi-source assessment tools for ACGME residents and fellows. MedEDPORTAL. 2014. Accessed May 14, 2026. doi:10.15766/mep_2374-8265.9839
The Development of a Comprehensive Wound Care Fellowship Curriculum
The Development of a Comprehensive Wound Care Fellowship Curriculum
