The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The number and rate of U.S. abortions increased between 2017 and 2020 after a 30-year decline, according to a new report from the Guttmacher Institute.

More than 930,000 abortions took place in the United States in 2020, up 8% from 862,000 abortions in 2017. About one in five pregnancies ended in abortion in 2020, the report said.

The Guttmacher Institute, a research organization that supports abortion rights, said the trend shows a rising need for abortion care as the Supreme Court is poised to overturn the Roe v. Wade decision in coming weeks.

National abortion numbers reached the lowest point in 2017 since the landmark 1973 ruling that legalized the procedure. In the years following the ruling, abortion numbers rose above 1.5 million annually throughout the 1980s and then began declining in the 1990s, though they remained above 1 million annually through the early 2010s.

The latest data show that the abortion rate increased from 13.5 abortions per 1,000 women between ages 15 and 44 in 2017 to 14.4 abortions per 1,000 women in 2020, marking a 7% increase.

Similarly, the abortion ratio – or the number of abortions per 100 pregnancies – increased from 18.4% in 2017 to 20.6% in 2020, marking a 12% increase.

The increase in abortions was accompanied by a 6% decline in births between 2017 and 2020, the Guttmacher Institute said.

“Because there were many more births (3.6 million) than abortions (930,000) in 2020, these patterns mean that fewer people were getting pregnant and, among those who did, a larger proportion chose to have an abortion,” the institute wrote.

Medication-related abortions accounted for 54% of U.S. abortions in 2020, according to the report, which was the first time they made up more than half of abortions.

The number of abortions increased in every region of the country between 2017 and 2020, the report shows. The increases were largest in the West (12%) and Midwest (10%), followed by 8% in the South and 2% in the Northeast.

In some states – Illinois, Mississippi, and Oklahoma – there were substantial increases in the number of abortions, the institute said. In others – such as Missouri, Oregon, and North Dakota – there were substantially fewer abortions in 2020, compared with 2017.

The COVID-19 pandemic may have led to a decline in some states. In New York, abortions increased 5% from 2017 to 2019 and then fell 6% between 2019 and 2020. About 10% of clinics in New York paused or stopped abortion care in 2020 when the pandemic started.

New laws likely affected the numbers as well. Texas had a 7% increase between 2017 and 2019, followed by a 2% decrease between 2019 and 2020, which overlapped with restrictions that deemed abortions “nonessential” health care at the beginning of the pandemic.

In contrast, some numbers may have increased because of expanded Medicaid funding. Illinois began allowing state Medicaid funds to pay for abortions in January 2018, and abortions increased 25% between 2017 and 2020.

In Missouri, abortions decreased substantially from 4,710 in 2017 to 170 in 2020, the report shows, but the number of Missouri residents who traveled to Illinois for abortions increased to more than 6,500.

Every 3 years, the Guttmacher Institute contacts U.S. facilities that provide abortions to collect information about services, including the total number of abortions. The most recent count was completed in May, representing 1,687 health care facilities that provided abortions in 2019 or 2020. A full summary of the data will be published later this year in a peer-reviewed journal article.

A version of this article first appeared on WebMD.com.

The number and rate of U.S. abortions increased between 2017 and 2020 after a 30-year decline, according to a new report from the Guttmacher Institute.

More than 930,000 abortions took place in the United States in 2020, up 8% from 862,000 abortions in 2017. About one in five pregnancies ended in abortion in 2020, the report said.

The Guttmacher Institute, a research organization that supports abortion rights, said the trend shows a rising need for abortion care as the Supreme Court is poised to overturn the Roe v. Wade decision in coming weeks.

National abortion numbers reached the lowest point in 2017 since the landmark 1973 ruling that legalized the procedure. In the years following the ruling, abortion numbers rose above 1.5 million annually throughout the 1980s and then began declining in the 1990s, though they remained above 1 million annually through the early 2010s.

The latest data show that the abortion rate increased from 13.5 abortions per 1,000 women between ages 15 and 44 in 2017 to 14.4 abortions per 1,000 women in 2020, marking a 7% increase.

Similarly, the abortion ratio – or the number of abortions per 100 pregnancies – increased from 18.4% in 2017 to 20.6% in 2020, marking a 12% increase.

The increase in abortions was accompanied by a 6% decline in births between 2017 and 2020, the Guttmacher Institute said.

“Because there were many more births (3.6 million) than abortions (930,000) in 2020, these patterns mean that fewer people were getting pregnant and, among those who did, a larger proportion chose to have an abortion,” the institute wrote.

Medication-related abortions accounted for 54% of U.S. abortions in 2020, according to the report, which was the first time they made up more than half of abortions.

The number of abortions increased in every region of the country between 2017 and 2020, the report shows. The increases were largest in the West (12%) and Midwest (10%), followed by 8% in the South and 2% in the Northeast.

In some states – Illinois, Mississippi, and Oklahoma – there were substantial increases in the number of abortions, the institute said. In others – such as Missouri, Oregon, and North Dakota – there were substantially fewer abortions in 2020, compared with 2017.

The COVID-19 pandemic may have led to a decline in some states. In New York, abortions increased 5% from 2017 to 2019 and then fell 6% between 2019 and 2020. About 10% of clinics in New York paused or stopped abortion care in 2020 when the pandemic started.

New laws likely affected the numbers as well. Texas had a 7% increase between 2017 and 2019, followed by a 2% decrease between 2019 and 2020, which overlapped with restrictions that deemed abortions “nonessential” health care at the beginning of the pandemic.

In contrast, some numbers may have increased because of expanded Medicaid funding. Illinois began allowing state Medicaid funds to pay for abortions in January 2018, and abortions increased 25% between 2017 and 2020.

In Missouri, abortions decreased substantially from 4,710 in 2017 to 170 in 2020, the report shows, but the number of Missouri residents who traveled to Illinois for abortions increased to more than 6,500.

Every 3 years, the Guttmacher Institute contacts U.S. facilities that provide abortions to collect information about services, including the total number of abortions. The most recent count was completed in May, representing 1,687 health care facilities that provided abortions in 2019 or 2020. A full summary of the data will be published later this year in a peer-reviewed journal article.

A version of this article first appeared on WebMD.com.

The number and rate of U.S. abortions increased between 2017 and 2020 after a 30-year decline, according to a new report from the Guttmacher Institute.

More than 930,000 abortions took place in the United States in 2020, up 8% from 862,000 abortions in 2017. About one in five pregnancies ended in abortion in 2020, the report said.

The Guttmacher Institute, a research organization that supports abortion rights, said the trend shows a rising need for abortion care as the Supreme Court is poised to overturn the Roe v. Wade decision in coming weeks.

National abortion numbers reached the lowest point in 2017 since the landmark 1973 ruling that legalized the procedure. In the years following the ruling, abortion numbers rose above 1.5 million annually throughout the 1980s and then began declining in the 1990s, though they remained above 1 million annually through the early 2010s.

The latest data show that the abortion rate increased from 13.5 abortions per 1,000 women between ages 15 and 44 in 2017 to 14.4 abortions per 1,000 women in 2020, marking a 7% increase.

Similarly, the abortion ratio – or the number of abortions per 100 pregnancies – increased from 18.4% in 2017 to 20.6% in 2020, marking a 12% increase.

The increase in abortions was accompanied by a 6% decline in births between 2017 and 2020, the Guttmacher Institute said.

“Because there were many more births (3.6 million) than abortions (930,000) in 2020, these patterns mean that fewer people were getting pregnant and, among those who did, a larger proportion chose to have an abortion,” the institute wrote.

Medication-related abortions accounted for 54% of U.S. abortions in 2020, according to the report, which was the first time they made up more than half of abortions.

The number of abortions increased in every region of the country between 2017 and 2020, the report shows. The increases were largest in the West (12%) and Midwest (10%), followed by 8% in the South and 2% in the Northeast.

In some states – Illinois, Mississippi, and Oklahoma – there were substantial increases in the number of abortions, the institute said. In others – such as Missouri, Oregon, and North Dakota – there were substantially fewer abortions in 2020, compared with 2017.

The COVID-19 pandemic may have led to a decline in some states. In New York, abortions increased 5% from 2017 to 2019 and then fell 6% between 2019 and 2020. About 10% of clinics in New York paused or stopped abortion care in 2020 when the pandemic started.

New laws likely affected the numbers as well. Texas had a 7% increase between 2017 and 2019, followed by a 2% decrease between 2019 and 2020, which overlapped with restrictions that deemed abortions “nonessential” health care at the beginning of the pandemic.

In contrast, some numbers may have increased because of expanded Medicaid funding. Illinois began allowing state Medicaid funds to pay for abortions in January 2018, and abortions increased 25% between 2017 and 2020.

In Missouri, abortions decreased substantially from 4,710 in 2017 to 170 in 2020, the report shows, but the number of Missouri residents who traveled to Illinois for abortions increased to more than 6,500.

Every 3 years, the Guttmacher Institute contacts U.S. facilities that provide abortions to collect information about services, including the total number of abortions. The most recent count was completed in May, representing 1,687 health care facilities that provided abortions in 2019 or 2020. A full summary of the data will be published later this year in a peer-reviewed journal article.

A version of this article first appeared on WebMD.com.

Adults with type 1 diabetes had significantly better glycemic control on days they exercised, regardless of exercise type, compared to days when they were inactive, according to a prospective study in nearly 500 individuals.

Different types of exercise, such as aerobic workouts, interval training, or resistance training, may have different immediate glycemic effects in adults with type 1 diabetes (T1D), but the impact of exercise type on the percentage of time diabetes patients maintain glucose in the 70-180 mg/dL range on days when they are active vs. inactive has not been well studied, Zoey Li said in a presentation at the annual scientific sessions of the American Diabetes Association.

Yuri Nunes / EyeEm / Getty Images

In the Type 1 Diabetes Exercise Initiative (T1DEXI) study, Ms. Li and colleagues examined continuous glucose monitoring (CGM) data from 497 adults with T1D. The observational study included self-referred adults aged 18 years and older who had been living with T1D for at least 2 years. Participants were assigned to programs of aerobic exercise (defined as a target heart rate of 70%-80% of age-predicted maximum), interval exercise (defined as an interval heart rate of 80%-90% of age-predicted maximum), or resistance exercise (defined as muscle group fatigue after three sets of eight repetitions).

Participants completed the workouts at home via 30-minute videos at least six times over the 4-week study period. The study design involved an activity goal of at least 150 minutes per week, including the videos and self-reported usual activity, such as walking. The data were collected through an app designed for the study, a heart rate monitor, and a CGM.

The researchers compared glucose levels on days when the participants reported being active compared to days when they were sedentary. The goal of the study was to assess the effect of exercise type on time spent with glucose in the range of 70-180 mg/dL, defined as time in range (TIR).

The mean age of the participants was 37 years; 89% were White. The mean duration of diabetes was 18 years, and the mean hemoglobin A1c was 6.6%. “An astounding 95% were current continuous glucose monitoring [CGM] users,” said Ms. Li, a statistician at the Jaeb Center for Health Research in Tampa, Fla.

A total of 398 participants reported at least one exercise day and one sedentary day, for a total of 1,302 exercise days and 2,470 sedentary days.

Overall, the mean TIR was significantly higher on exercise days compared to sedentary days (75% vs. 70%, P < .001). The median time above 180 mg/dL also was significantly lower on exercise days compared to sedentary days (17% vs. 23%, P < .001), and mean glucose levels were 10 mg/dL lower on exercise days (145 mg/dL vs. 155 mg/dL)

“This all came with a slight hit to their time below range,” Ms. Li noted. The median time below 70 mg/dL was 1.1% on exercise days compared to 0.4% on sedentary days (P < .001). The percentage of days with hypoglycemic events was higher on exercise days compared to sedentary days (47% vs. 40%, P < .001), as they are related to time below 70 mg/dL, she added.

The differences for mean glucose level and TIR between exercise days and sedentary days were significant for each of the three exercise types, Ms. Li said.

“After establishing these glycemic trends, we looked at whether there were any factors that influenced the glycemic differences on exercise vs. sedentary days,” Ms. Li said.

Regardless of exercise type, age, sex, baseline A1c, diabetes duration, body mass index, insulin modality, CGM use, and percentage of time below range in the past 24 hours, there was higher TIR and higher hypoglycemia on exercise days compared to sedentary days.

Although the study was limited in part by the observational design, “with these data, we can better understand the glycemic benefits and disadvantages of exercise in adults with type 1 diabetes,” Ms. Li said.
 

Don’t forget the negative effects of exercise

“It is well known that the three types of exercise can modulate glucose levels. This can be very useful when attempting to reduce excessively high glucose levels, and when encouraging people to engage in frequent, regular, and consistent physical activity and exercise for general cardiovascular pulmonary and musculoskeletal health,” Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., said in an interview.

“However, it was not known what effects various types of exercise would have on time in range (70-180 mg/dL) and time below range (< 70 mg/dL) measured over a full 24-hour period in people with type 1 diabetes,” said Dr. Rodbard, who was not involved with the study.

“I was surprised to see that the effect of the three different types of exercise were so similar,” Dr. Rodbard noted. “There had been previous reports suggesting that the time course of glucose could be different for these three types of exercise.”

The current study confirms prior knowledge that exercise can help reduce blood glucose, and increase TIR, said Dr. Rodbard. The study shows that TIR increases by roughly 5-7 percentage points (about 1 hour per day) and reduces mean glucose by 9-13 mg/dL irrespective of the three types of exercise,” she said. “There was a suggestion that the risk of increasing hypoglycemia below 70 mg/dL was less likely for resistance exercise than for the interval or aerobic types of exercise,” she noted.

As for additional research, “This study did not address the various ways in which one can mitigate the potentially deleterious effects of exercise, specifically with reference to rates of hypoglycemia, even mild symptomatic biochemical hypoglycemia,” said Dr. Rodbard. “Since the actual amount of time below 70 mg/dL is usually so small (0.3%-0.7% of the 1,440 minutes in the day, or about 5-10 minutes per day on average), it is difficult to measure and there is considerable variability between different people,” she emphasized. “Finding optimal and robust ways to achieve consistency in the reduction of glucose, between days within subjects, and between subjects, will need further examination of various types of protocols for diet, exercise and insulin administration, and of various methods for education of the patient,” she said.

The study was supported in part by the Leona M. and Harry B. Helmsley Charitable Trust. Ms. Li and Dr. Rodbard had no financial conflicts to disclose. Dr. Rodbard serves on the editorial advisory board of Clinical Endocrinology News.

Adults with type 1 diabetes had significantly better glycemic control on days they exercised, regardless of exercise type, compared to days when they were inactive, according to a prospective study in nearly 500 individuals.

Different types of exercise, such as aerobic workouts, interval training, or resistance training, may have different immediate glycemic effects in adults with type 1 diabetes (T1D), but the impact of exercise type on the percentage of time diabetes patients maintain glucose in the 70-180 mg/dL range on days when they are active vs. inactive has not been well studied, Zoey Li said in a presentation at the annual scientific sessions of the American Diabetes Association.

Yuri Nunes / EyeEm / Getty Images

In the Type 1 Diabetes Exercise Initiative (T1DEXI) study, Ms. Li and colleagues examined continuous glucose monitoring (CGM) data from 497 adults with T1D. The observational study included self-referred adults aged 18 years and older who had been living with T1D for at least 2 years. Participants were assigned to programs of aerobic exercise (defined as a target heart rate of 70%-80% of age-predicted maximum), interval exercise (defined as an interval heart rate of 80%-90% of age-predicted maximum), or resistance exercise (defined as muscle group fatigue after three sets of eight repetitions).

Participants completed the workouts at home via 30-minute videos at least six times over the 4-week study period. The study design involved an activity goal of at least 150 minutes per week, including the videos and self-reported usual activity, such as walking. The data were collected through an app designed for the study, a heart rate monitor, and a CGM.

The researchers compared glucose levels on days when the participants reported being active compared to days when they were sedentary. The goal of the study was to assess the effect of exercise type on time spent with glucose in the range of 70-180 mg/dL, defined as time in range (TIR).

The mean age of the participants was 37 years; 89% were White. The mean duration of diabetes was 18 years, and the mean hemoglobin A1c was 6.6%. “An astounding 95% were current continuous glucose monitoring [CGM] users,” said Ms. Li, a statistician at the Jaeb Center for Health Research in Tampa, Fla.

A total of 398 participants reported at least one exercise day and one sedentary day, for a total of 1,302 exercise days and 2,470 sedentary days.

Overall, the mean TIR was significantly higher on exercise days compared to sedentary days (75% vs. 70%, P < .001). The median time above 180 mg/dL also was significantly lower on exercise days compared to sedentary days (17% vs. 23%, P < .001), and mean glucose levels were 10 mg/dL lower on exercise days (145 mg/dL vs. 155 mg/dL)

“This all came with a slight hit to their time below range,” Ms. Li noted. The median time below 70 mg/dL was 1.1% on exercise days compared to 0.4% on sedentary days (P < .001). The percentage of days with hypoglycemic events was higher on exercise days compared to sedentary days (47% vs. 40%, P < .001), as they are related to time below 70 mg/dL, she added.

The differences for mean glucose level and TIR between exercise days and sedentary days were significant for each of the three exercise types, Ms. Li said.

“After establishing these glycemic trends, we looked at whether there were any factors that influenced the glycemic differences on exercise vs. sedentary days,” Ms. Li said.

Regardless of exercise type, age, sex, baseline A1c, diabetes duration, body mass index, insulin modality, CGM use, and percentage of time below range in the past 24 hours, there was higher TIR and higher hypoglycemia on exercise days compared to sedentary days.

Although the study was limited in part by the observational design, “with these data, we can better understand the glycemic benefits and disadvantages of exercise in adults with type 1 diabetes,” Ms. Li said.
 

Don’t forget the negative effects of exercise

“It is well known that the three types of exercise can modulate glucose levels. This can be very useful when attempting to reduce excessively high glucose levels, and when encouraging people to engage in frequent, regular, and consistent physical activity and exercise for general cardiovascular pulmonary and musculoskeletal health,” Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., said in an interview.

“However, it was not known what effects various types of exercise would have on time in range (70-180 mg/dL) and time below range (< 70 mg/dL) measured over a full 24-hour period in people with type 1 diabetes,” said Dr. Rodbard, who was not involved with the study.

“I was surprised to see that the effect of the three different types of exercise were so similar,” Dr. Rodbard noted. “There had been previous reports suggesting that the time course of glucose could be different for these three types of exercise.”

The current study confirms prior knowledge that exercise can help reduce blood glucose, and increase TIR, said Dr. Rodbard. The study shows that TIR increases by roughly 5-7 percentage points (about 1 hour per day) and reduces mean glucose by 9-13 mg/dL irrespective of the three types of exercise,” she said. “There was a suggestion that the risk of increasing hypoglycemia below 70 mg/dL was less likely for resistance exercise than for the interval or aerobic types of exercise,” she noted.

As for additional research, “This study did not address the various ways in which one can mitigate the potentially deleterious effects of exercise, specifically with reference to rates of hypoglycemia, even mild symptomatic biochemical hypoglycemia,” said Dr. Rodbard. “Since the actual amount of time below 70 mg/dL is usually so small (0.3%-0.7% of the 1,440 minutes in the day, or about 5-10 minutes per day on average), it is difficult to measure and there is considerable variability between different people,” she emphasized. “Finding optimal and robust ways to achieve consistency in the reduction of glucose, between days within subjects, and between subjects, will need further examination of various types of protocols for diet, exercise and insulin administration, and of various methods for education of the patient,” she said.

The study was supported in part by the Leona M. and Harry B. Helmsley Charitable Trust. Ms. Li and Dr. Rodbard had no financial conflicts to disclose. Dr. Rodbard serves on the editorial advisory board of Clinical Endocrinology News.

Adults with type 1 diabetes had significantly better glycemic control on days they exercised, regardless of exercise type, compared to days when they were inactive, according to a prospective study in nearly 500 individuals.

Different types of exercise, such as aerobic workouts, interval training, or resistance training, may have different immediate glycemic effects in adults with type 1 diabetes (T1D), but the impact of exercise type on the percentage of time diabetes patients maintain glucose in the 70-180 mg/dL range on days when they are active vs. inactive has not been well studied, Zoey Li said in a presentation at the annual scientific sessions of the American Diabetes Association.

Yuri Nunes / EyeEm / Getty Images

In the Type 1 Diabetes Exercise Initiative (T1DEXI) study, Ms. Li and colleagues examined continuous glucose monitoring (CGM) data from 497 adults with T1D. The observational study included self-referred adults aged 18 years and older who had been living with T1D for at least 2 years. Participants were assigned to programs of aerobic exercise (defined as a target heart rate of 70%-80% of age-predicted maximum), interval exercise (defined as an interval heart rate of 80%-90% of age-predicted maximum), or resistance exercise (defined as muscle group fatigue after three sets of eight repetitions).

Participants completed the workouts at home via 30-minute videos at least six times over the 4-week study period. The study design involved an activity goal of at least 150 minutes per week, including the videos and self-reported usual activity, such as walking. The data were collected through an app designed for the study, a heart rate monitor, and a CGM.

The researchers compared glucose levels on days when the participants reported being active compared to days when they were sedentary. The goal of the study was to assess the effect of exercise type on time spent with glucose in the range of 70-180 mg/dL, defined as time in range (TIR).

The mean age of the participants was 37 years; 89% were White. The mean duration of diabetes was 18 years, and the mean hemoglobin A1c was 6.6%. “An astounding 95% were current continuous glucose monitoring [CGM] users,” said Ms. Li, a statistician at the Jaeb Center for Health Research in Tampa, Fla.

A total of 398 participants reported at least one exercise day and one sedentary day, for a total of 1,302 exercise days and 2,470 sedentary days.

Overall, the mean TIR was significantly higher on exercise days compared to sedentary days (75% vs. 70%, P < .001). The median time above 180 mg/dL also was significantly lower on exercise days compared to sedentary days (17% vs. 23%, P < .001), and mean glucose levels were 10 mg/dL lower on exercise days (145 mg/dL vs. 155 mg/dL)

“This all came with a slight hit to their time below range,” Ms. Li noted. The median time below 70 mg/dL was 1.1% on exercise days compared to 0.4% on sedentary days (P < .001). The percentage of days with hypoglycemic events was higher on exercise days compared to sedentary days (47% vs. 40%, P < .001), as they are related to time below 70 mg/dL, she added.

The differences for mean glucose level and TIR between exercise days and sedentary days were significant for each of the three exercise types, Ms. Li said.

“After establishing these glycemic trends, we looked at whether there were any factors that influenced the glycemic differences on exercise vs. sedentary days,” Ms. Li said.

Regardless of exercise type, age, sex, baseline A1c, diabetes duration, body mass index, insulin modality, CGM use, and percentage of time below range in the past 24 hours, there was higher TIR and higher hypoglycemia on exercise days compared to sedentary days.

Although the study was limited in part by the observational design, “with these data, we can better understand the glycemic benefits and disadvantages of exercise in adults with type 1 diabetes,” Ms. Li said.
 

Don’t forget the negative effects of exercise

“It is well known that the three types of exercise can modulate glucose levels. This can be very useful when attempting to reduce excessively high glucose levels, and when encouraging people to engage in frequent, regular, and consistent physical activity and exercise for general cardiovascular pulmonary and musculoskeletal health,” Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., said in an interview.

“However, it was not known what effects various types of exercise would have on time in range (70-180 mg/dL) and time below range (< 70 mg/dL) measured over a full 24-hour period in people with type 1 diabetes,” said Dr. Rodbard, who was not involved with the study.

“I was surprised to see that the effect of the three different types of exercise were so similar,” Dr. Rodbard noted. “There had been previous reports suggesting that the time course of glucose could be different for these three types of exercise.”

The current study confirms prior knowledge that exercise can help reduce blood glucose, and increase TIR, said Dr. Rodbard. The study shows that TIR increases by roughly 5-7 percentage points (about 1 hour per day) and reduces mean glucose by 9-13 mg/dL irrespective of the three types of exercise,” she said. “There was a suggestion that the risk of increasing hypoglycemia below 70 mg/dL was less likely for resistance exercise than for the interval or aerobic types of exercise,” she noted.

As for additional research, “This study did not address the various ways in which one can mitigate the potentially deleterious effects of exercise, specifically with reference to rates of hypoglycemia, even mild symptomatic biochemical hypoglycemia,” said Dr. Rodbard. “Since the actual amount of time below 70 mg/dL is usually so small (0.3%-0.7% of the 1,440 minutes in the day, or about 5-10 minutes per day on average), it is difficult to measure and there is considerable variability between different people,” she emphasized. “Finding optimal and robust ways to achieve consistency in the reduction of glucose, between days within subjects, and between subjects, will need further examination of various types of protocols for diet, exercise and insulin administration, and of various methods for education of the patient,” she said.

The study was supported in part by the Leona M. and Harry B. Helmsley Charitable Trust. Ms. Li and Dr. Rodbard had no financial conflicts to disclose. Dr. Rodbard serves on the editorial advisory board of Clinical Endocrinology News.

COPENHAGEN – For patients with active psoriatic arthritis for whom tumor necrosis factor (TNF) inhibitors failed to produce an adequate response, use of the dual interleukin-17 (IL-17) inhibitor bimekizumab (Bimzelx) was associated with significant improvement in joint, skin, and health-related quality-of-life parameters, compared with placebo, reported investigators in the phase 3, double-blind, randomized BE COMPLETE trial.

The primary endpoint, which was the percentage of patients who had 50% improvement in American College of Rheumatology response criteria (ACR50) at 16 weeks, was achieved in 43.4% of patients assigned to receive bimekizumab 160 mg every 4 weeks, compared with 6.8% among patients who received placebo, reported Joseph F. Merola, MD, a dermatologist and rheumatologist at Brigham and Women’s Hospital in Boston.

Neil Osterweil/Medscape

“The high-level and exciting take-home [message is] that BE COMPLETE did meet all primary and all ranked secondary endpoints at week 16,” he said at the annual European Congress of Rheumatology.

Also at the congress, Iain McInnes, MD, PhD, of the Institute of Infection, Immunity, and Inflammation at the University of Glasgow, Scotland, presented data from a second phase 3, double-blind, randomized trial called BE OPTIMAL that showed similar benefits for patients with psoriatic arthritis who had not previously received biologic disease-modifying antirheumatic drugs.

Neil Osterweil/Medscape

“This is a new mode of action, inhibiting two cytokines simultaneously,” he said in a late-breaking oral abstract session.

As previously reported by this news organization, use of bimekizumab led to rapid reductions in signs and symptoms of radiographic axial spondyloarthritis in the phase 3 trial called BE MOBILE 2.

Bimekizumab is a monoclonal immunoglobulin G1 antibody that selectively inhibits IL-17A and IL-17F. It is approved in the European Union for treating adults with moderate to severe plaque psoriasis.
 

BE COMPLETE efficacy

Inclusion criteria comprised adult-onset psoriatic arthritis meeting Classification Criteria for Psoriatic Arthritis (CASPAR) for at least 6 months; tender and swollen joint counts of at least 3/68; one or more active psoriatic lesions; and/or a documented history of psoriasis characterized by intolerance to one or two TNF inhibitors or failure of TNF inhibitors. Patients were randomly assigned in a 2:1 ratio to receive either bimekizumab 160 mg every 4 weeks (n = 267) or placebo (n = 133) for 16 weeks.

Some participants are being followed in the extension BE VITAL study, which will evaluate response to treatment and long-term safety. Patients who do enroll in the extension study will be followed for safety for a period of 20 weeks after the last dose.

As noted before, the trial met its primary endpoint of a significant improvement over placebo in ACR50 (hazard ratio, 11.1; P < .001).

In addition, the trial met all ranked secondary endpoints, including the Health Assessment Questionnaire–Disability Index change from baseline, 90% improvement in the Psoriasis Area and Severity Index (PASI90), Short-Form 36-Item Health Survey, and minimal disease activity (P < .001 for all comparisons).

Improvement with bimekizumab was rapid; curves began to separate from placebo by week 4, Dr. Merola said.

BE OPTIMAL efficacy

In this study, which had the same eligibility criteria as BE COMPLETE, patients were randomly assigned in a 2:3:1 ratio to receive 16 weeks of treatment with either placebo, bimekizumab 160 mg every 4 weeks, or adalimumab 40 mg every 2 weeks as a reference treatment.

This trial also met its primary and ranked secondary endpoints, which were similar to those of BE COMPLETE but also included measures of pooled resolution of enthesitis and dactylitis and change from baseline in van der Heijde modified total Sharp score (P < .001 for all comparisons).

In all, 43.9% of patients who received bimekizumab and 45.7% who received adalimumab achieved ACR50 at week 16, compared with 10% of patients who received placebo. The difference between the placebo and bimekizumab groups was significant (P < .001).
 

Safety

More patients who received the two active agents in this trial had treatment-emergent adverse events (TEAEs) in comparison with those in the placebo arm, but the incidence of serious TEAEs was less than 2% in each arm.

The most frequent events were nasopharyngitis, upper respiratory tract infection, headache, diarrhea, and hypertension.

Patients tolerated bimekizumab well, and there were no unexpected safety signals, Dr. McInnes said.
 

Clues to efficacy

In the question-and-answer session following Dr. McInnes’ presentation, Ronald Van Vollenhoven, MD, of the University of Amsterdam, said, “I have a question that is sort of generic in studies of psoriatic arthritis, so it does not only apply to this study, but the skin responses seem to be excellent – PASI90 sounds wonderful – but given that this is the case, is it reasonable to claim that the study is double-blinded in respect to the joints?”

Dr. McInnes replied that while he has considered this conundrum for many years in trials of drugs for psoriatic arthritis, “it doesn’t seem to be a major determinant of the outcome.”

The studies were supported by UCB Pharma. Dr. Merola and Dr. McInnes have consulted for UCB and other pharmaceutical companies that market drugs for psoriatic arthritis and psoriasis. Dr. Van Vollenhoven has received research support, has consulted for, and has spoken on behalf of UCB and other pharmaceutical companies.

A version of this article first appeared on Medscape.com.

COPENHAGEN – For patients with active psoriatic arthritis for whom tumor necrosis factor (TNF) inhibitors failed to produce an adequate response, use of the dual interleukin-17 (IL-17) inhibitor bimekizumab (Bimzelx) was associated with significant improvement in joint, skin, and health-related quality-of-life parameters, compared with placebo, reported investigators in the phase 3, double-blind, randomized BE COMPLETE trial.

The primary endpoint, which was the percentage of patients who had 50% improvement in American College of Rheumatology response criteria (ACR50) at 16 weeks, was achieved in 43.4% of patients assigned to receive bimekizumab 160 mg every 4 weeks, compared with 6.8% among patients who received placebo, reported Joseph F. Merola, MD, a dermatologist and rheumatologist at Brigham and Women’s Hospital in Boston.

Neil Osterweil/Medscape

“The high-level and exciting take-home [message is] that BE COMPLETE did meet all primary and all ranked secondary endpoints at week 16,” he said at the annual European Congress of Rheumatology.

Also at the congress, Iain McInnes, MD, PhD, of the Institute of Infection, Immunity, and Inflammation at the University of Glasgow, Scotland, presented data from a second phase 3, double-blind, randomized trial called BE OPTIMAL that showed similar benefits for patients with psoriatic arthritis who had not previously received biologic disease-modifying antirheumatic drugs.

Neil Osterweil/Medscape

“This is a new mode of action, inhibiting two cytokines simultaneously,” he said in a late-breaking oral abstract session.

As previously reported by this news organization, use of bimekizumab led to rapid reductions in signs and symptoms of radiographic axial spondyloarthritis in the phase 3 trial called BE MOBILE 2.

Bimekizumab is a monoclonal immunoglobulin G1 antibody that selectively inhibits IL-17A and IL-17F. It is approved in the European Union for treating adults with moderate to severe plaque psoriasis.
 

BE COMPLETE efficacy

Inclusion criteria comprised adult-onset psoriatic arthritis meeting Classification Criteria for Psoriatic Arthritis (CASPAR) for at least 6 months; tender and swollen joint counts of at least 3/68; one or more active psoriatic lesions; and/or a documented history of psoriasis characterized by intolerance to one or two TNF inhibitors or failure of TNF inhibitors. Patients were randomly assigned in a 2:1 ratio to receive either bimekizumab 160 mg every 4 weeks (n = 267) or placebo (n = 133) for 16 weeks.

Some participants are being followed in the extension BE VITAL study, which will evaluate response to treatment and long-term safety. Patients who do enroll in the extension study will be followed for safety for a period of 20 weeks after the last dose.

As noted before, the trial met its primary endpoint of a significant improvement over placebo in ACR50 (hazard ratio, 11.1; P < .001).

In addition, the trial met all ranked secondary endpoints, including the Health Assessment Questionnaire–Disability Index change from baseline, 90% improvement in the Psoriasis Area and Severity Index (PASI90), Short-Form 36-Item Health Survey, and minimal disease activity (P < .001 for all comparisons).

Improvement with bimekizumab was rapid; curves began to separate from placebo by week 4, Dr. Merola said.

BE OPTIMAL efficacy

In this study, which had the same eligibility criteria as BE COMPLETE, patients were randomly assigned in a 2:3:1 ratio to receive 16 weeks of treatment with either placebo, bimekizumab 160 mg every 4 weeks, or adalimumab 40 mg every 2 weeks as a reference treatment.

This trial also met its primary and ranked secondary endpoints, which were similar to those of BE COMPLETE but also included measures of pooled resolution of enthesitis and dactylitis and change from baseline in van der Heijde modified total Sharp score (P < .001 for all comparisons).

In all, 43.9% of patients who received bimekizumab and 45.7% who received adalimumab achieved ACR50 at week 16, compared with 10% of patients who received placebo. The difference between the placebo and bimekizumab groups was significant (P < .001).
 

Safety

More patients who received the two active agents in this trial had treatment-emergent adverse events (TEAEs) in comparison with those in the placebo arm, but the incidence of serious TEAEs was less than 2% in each arm.

The most frequent events were nasopharyngitis, upper respiratory tract infection, headache, diarrhea, and hypertension.

Patients tolerated bimekizumab well, and there were no unexpected safety signals, Dr. McInnes said.
 

Clues to efficacy

In the question-and-answer session following Dr. McInnes’ presentation, Ronald Van Vollenhoven, MD, of the University of Amsterdam, said, “I have a question that is sort of generic in studies of psoriatic arthritis, so it does not only apply to this study, but the skin responses seem to be excellent – PASI90 sounds wonderful – but given that this is the case, is it reasonable to claim that the study is double-blinded in respect to the joints?”

Dr. McInnes replied that while he has considered this conundrum for many years in trials of drugs for psoriatic arthritis, “it doesn’t seem to be a major determinant of the outcome.”

The studies were supported by UCB Pharma. Dr. Merola and Dr. McInnes have consulted for UCB and other pharmaceutical companies that market drugs for psoriatic arthritis and psoriasis. Dr. Van Vollenhoven has received research support, has consulted for, and has spoken on behalf of UCB and other pharmaceutical companies.

A version of this article first appeared on Medscape.com.

COPENHAGEN – For patients with active psoriatic arthritis for whom tumor necrosis factor (TNF) inhibitors failed to produce an adequate response, use of the dual interleukin-17 (IL-17) inhibitor bimekizumab (Bimzelx) was associated with significant improvement in joint, skin, and health-related quality-of-life parameters, compared with placebo, reported investigators in the phase 3, double-blind, randomized BE COMPLETE trial.

The primary endpoint, which was the percentage of patients who had 50% improvement in American College of Rheumatology response criteria (ACR50) at 16 weeks, was achieved in 43.4% of patients assigned to receive bimekizumab 160 mg every 4 weeks, compared with 6.8% among patients who received placebo, reported Joseph F. Merola, MD, a dermatologist and rheumatologist at Brigham and Women’s Hospital in Boston.

Neil Osterweil/Medscape

“The high-level and exciting take-home [message is] that BE COMPLETE did meet all primary and all ranked secondary endpoints at week 16,” he said at the annual European Congress of Rheumatology.

Also at the congress, Iain McInnes, MD, PhD, of the Institute of Infection, Immunity, and Inflammation at the University of Glasgow, Scotland, presented data from a second phase 3, double-blind, randomized trial called BE OPTIMAL that showed similar benefits for patients with psoriatic arthritis who had not previously received biologic disease-modifying antirheumatic drugs.

Neil Osterweil/Medscape

“This is a new mode of action, inhibiting two cytokines simultaneously,” he said in a late-breaking oral abstract session.

As previously reported by this news organization, use of bimekizumab led to rapid reductions in signs and symptoms of radiographic axial spondyloarthritis in the phase 3 trial called BE MOBILE 2.

Bimekizumab is a monoclonal immunoglobulin G1 antibody that selectively inhibits IL-17A and IL-17F. It is approved in the European Union for treating adults with moderate to severe plaque psoriasis.
 

BE COMPLETE efficacy

Inclusion criteria comprised adult-onset psoriatic arthritis meeting Classification Criteria for Psoriatic Arthritis (CASPAR) for at least 6 months; tender and swollen joint counts of at least 3/68; one or more active psoriatic lesions; and/or a documented history of psoriasis characterized by intolerance to one or two TNF inhibitors or failure of TNF inhibitors. Patients were randomly assigned in a 2:1 ratio to receive either bimekizumab 160 mg every 4 weeks (n = 267) or placebo (n = 133) for 16 weeks.

Some participants are being followed in the extension BE VITAL study, which will evaluate response to treatment and long-term safety. Patients who do enroll in the extension study will be followed for safety for a period of 20 weeks after the last dose.

As noted before, the trial met its primary endpoint of a significant improvement over placebo in ACR50 (hazard ratio, 11.1; P < .001).

In addition, the trial met all ranked secondary endpoints, including the Health Assessment Questionnaire–Disability Index change from baseline, 90% improvement in the Psoriasis Area and Severity Index (PASI90), Short-Form 36-Item Health Survey, and minimal disease activity (P < .001 for all comparisons).

Improvement with bimekizumab was rapid; curves began to separate from placebo by week 4, Dr. Merola said.

BE OPTIMAL efficacy

In this study, which had the same eligibility criteria as BE COMPLETE, patients were randomly assigned in a 2:3:1 ratio to receive 16 weeks of treatment with either placebo, bimekizumab 160 mg every 4 weeks, or adalimumab 40 mg every 2 weeks as a reference treatment.

This trial also met its primary and ranked secondary endpoints, which were similar to those of BE COMPLETE but also included measures of pooled resolution of enthesitis and dactylitis and change from baseline in van der Heijde modified total Sharp score (P < .001 for all comparisons).

In all, 43.9% of patients who received bimekizumab and 45.7% who received adalimumab achieved ACR50 at week 16, compared with 10% of patients who received placebo. The difference between the placebo and bimekizumab groups was significant (P < .001).
 

Safety

More patients who received the two active agents in this trial had treatment-emergent adverse events (TEAEs) in comparison with those in the placebo arm, but the incidence of serious TEAEs was less than 2% in each arm.

The most frequent events were nasopharyngitis, upper respiratory tract infection, headache, diarrhea, and hypertension.

Patients tolerated bimekizumab well, and there were no unexpected safety signals, Dr. McInnes said.
 

Clues to efficacy

In the question-and-answer session following Dr. McInnes’ presentation, Ronald Van Vollenhoven, MD, of the University of Amsterdam, said, “I have a question that is sort of generic in studies of psoriatic arthritis, so it does not only apply to this study, but the skin responses seem to be excellent – PASI90 sounds wonderful – but given that this is the case, is it reasonable to claim that the study is double-blinded in respect to the joints?”

Dr. McInnes replied that while he has considered this conundrum for many years in trials of drugs for psoriatic arthritis, “it doesn’t seem to be a major determinant of the outcome.”

The studies were supported by UCB Pharma. Dr. Merola and Dr. McInnes have consulted for UCB and other pharmaceutical companies that market drugs for psoriatic arthritis and psoriasis. Dr. Van Vollenhoven has received research support, has consulted for, and has spoken on behalf of UCB and other pharmaceutical companies.

A version of this article first appeared on Medscape.com.

Following a diet rich in healthy plant-based products may lower one’s risk of breast cancer, but not if that diet happens to be high in unhealthy foods, researchers have found.

The study of more than 65,000 people showed that plant-based diets that were high in whole grains, fruits, and vegetables appear to be more protective against breast cancer than diets rich in processed plant-based products, such as juice and chips.

“Results suggest that the best plant-based diet for breast cancer prevention could be a healthy plant-based diet comprising fruit, vegetables, whole grains, nuts, and legumes,” said Sanam Shah, MBBS, FCPS, MPH, a doctoral candidate in epidemiology at Paris-Saclay University, who is the lead author of the new study. “In contrast, an unhealthy plant-based diet comprising higher intakes of primarily processed products of plant origin, such as refined grains, fruit juices, sweets, desserts, and potatoes, would be worse for breast cancer prevention.”

Dr. Shah’s group is presenting their research online at the annual meeting of the American Society for Nutrition.

Although the role of plant-based diets in cancer prevention has received extensive attention, Dr. Shah said few studies have assessed the influence of the quality of those diets on the risk of breast cancer.

Dr. Shah and colleagues conducted a prospective cohort study to investigate the link between healthy and unhealthy plant-based diets and breast cancer risk. Unlike other studies, the researchers also evaluated the effect of a gradual decrease in animal products in diets on health.

Dr. Shah’s group followed 65,574 postmenopausal women in France (mean age, 52.8 years) from 1993 to 2014. The researchers used self-reported food questionnaires to classify women into groups on the basis of adherence to a mostly plant or animal diet. Plant-based diets did not exclude meat but had more plant than animal products, Dr. Shah said. The researchers also grouped women on the basis of how healthy the plant-based diets were.

Over the 21-year study period, 3,968 women were diagnosed with breast cancer. Those who adhered to a more healthful plant-based diet had a 14% lower risk than average of developing breast cancer, while those who adhered to a less healthful plant-based diet had a 20% greater risk of developing the disease.

Nutritional quality varies greatly across plant-based foods. Quality plant-based diets should focus on variety to avoid nutritional deficiencies in iron, zinc, calcium, and vitamin B12, Dr. Shah said.

“The study by Shah and coworkers underscores the importance of considering more global aspects of the diet rather than single components when examining relationships between diet and health,” said Megan McCrory, PhD, research associate professor of nutrition at Boston University. “As the study illustrates, plant-based diets as a whole are not always healthy and may also contain less desirable nutrients and foods.”

Abstracts in the conference have been selected by a board of experts for presentation but have not yet been peer reviewed. All findings are to be regarded as preliminary until they are published in peer-reviewed articles. Dr. Shah and Dr. McCrory disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Following a diet rich in healthy plant-based products may lower one’s risk of breast cancer, but not if that diet happens to be high in unhealthy foods, researchers have found.

The study of more than 65,000 people showed that plant-based diets that were high in whole grains, fruits, and vegetables appear to be more protective against breast cancer than diets rich in processed plant-based products, such as juice and chips.

“Results suggest that the best plant-based diet for breast cancer prevention could be a healthy plant-based diet comprising fruit, vegetables, whole grains, nuts, and legumes,” said Sanam Shah, MBBS, FCPS, MPH, a doctoral candidate in epidemiology at Paris-Saclay University, who is the lead author of the new study. “In contrast, an unhealthy plant-based diet comprising higher intakes of primarily processed products of plant origin, such as refined grains, fruit juices, sweets, desserts, and potatoes, would be worse for breast cancer prevention.”

Dr. Shah’s group is presenting their research online at the annual meeting of the American Society for Nutrition.

Although the role of plant-based diets in cancer prevention has received extensive attention, Dr. Shah said few studies have assessed the influence of the quality of those diets on the risk of breast cancer.

Dr. Shah and colleagues conducted a prospective cohort study to investigate the link between healthy and unhealthy plant-based diets and breast cancer risk. Unlike other studies, the researchers also evaluated the effect of a gradual decrease in animal products in diets on health.

Dr. Shah’s group followed 65,574 postmenopausal women in France (mean age, 52.8 years) from 1993 to 2014. The researchers used self-reported food questionnaires to classify women into groups on the basis of adherence to a mostly plant or animal diet. Plant-based diets did not exclude meat but had more plant than animal products, Dr. Shah said. The researchers also grouped women on the basis of how healthy the plant-based diets were.

Over the 21-year study period, 3,968 women were diagnosed with breast cancer. Those who adhered to a more healthful plant-based diet had a 14% lower risk than average of developing breast cancer, while those who adhered to a less healthful plant-based diet had a 20% greater risk of developing the disease.

Nutritional quality varies greatly across plant-based foods. Quality plant-based diets should focus on variety to avoid nutritional deficiencies in iron, zinc, calcium, and vitamin B12, Dr. Shah said.

“The study by Shah and coworkers underscores the importance of considering more global aspects of the diet rather than single components when examining relationships between diet and health,” said Megan McCrory, PhD, research associate professor of nutrition at Boston University. “As the study illustrates, plant-based diets as a whole are not always healthy and may also contain less desirable nutrients and foods.”

Abstracts in the conference have been selected by a board of experts for presentation but have not yet been peer reviewed. All findings are to be regarded as preliminary until they are published in peer-reviewed articles. Dr. Shah and Dr. McCrory disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Following a diet rich in healthy plant-based products may lower one’s risk of breast cancer, but not if that diet happens to be high in unhealthy foods, researchers have found.

The study of more than 65,000 people showed that plant-based diets that were high in whole grains, fruits, and vegetables appear to be more protective against breast cancer than diets rich in processed plant-based products, such as juice and chips.

“Results suggest that the best plant-based diet for breast cancer prevention could be a healthy plant-based diet comprising fruit, vegetables, whole grains, nuts, and legumes,” said Sanam Shah, MBBS, FCPS, MPH, a doctoral candidate in epidemiology at Paris-Saclay University, who is the lead author of the new study. “In contrast, an unhealthy plant-based diet comprising higher intakes of primarily processed products of plant origin, such as refined grains, fruit juices, sweets, desserts, and potatoes, would be worse for breast cancer prevention.”

Dr. Shah’s group is presenting their research online at the annual meeting of the American Society for Nutrition.

Although the role of plant-based diets in cancer prevention has received extensive attention, Dr. Shah said few studies have assessed the influence of the quality of those diets on the risk of breast cancer.

Dr. Shah and colleagues conducted a prospective cohort study to investigate the link between healthy and unhealthy plant-based diets and breast cancer risk. Unlike other studies, the researchers also evaluated the effect of a gradual decrease in animal products in diets on health.

Dr. Shah’s group followed 65,574 postmenopausal women in France (mean age, 52.8 years) from 1993 to 2014. The researchers used self-reported food questionnaires to classify women into groups on the basis of adherence to a mostly plant or animal diet. Plant-based diets did not exclude meat but had more plant than animal products, Dr. Shah said. The researchers also grouped women on the basis of how healthy the plant-based diets were.

Over the 21-year study period, 3,968 women were diagnosed with breast cancer. Those who adhered to a more healthful plant-based diet had a 14% lower risk than average of developing breast cancer, while those who adhered to a less healthful plant-based diet had a 20% greater risk of developing the disease.

Nutritional quality varies greatly across plant-based foods. Quality plant-based diets should focus on variety to avoid nutritional deficiencies in iron, zinc, calcium, and vitamin B12, Dr. Shah said.

“The study by Shah and coworkers underscores the importance of considering more global aspects of the diet rather than single components when examining relationships between diet and health,” said Megan McCrory, PhD, research associate professor of nutrition at Boston University. “As the study illustrates, plant-based diets as a whole are not always healthy and may also contain less desirable nutrients and foods.”

Abstracts in the conference have been selected by a board of experts for presentation but have not yet been peer reviewed. All findings are to be regarded as preliminary until they are published in peer-reviewed articles. Dr. Shah and Dr. McCrory disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Poor sleep quality was linked to an increased risk of life-threatening exacerbations in people with chronic obstructive pulmonary disease (COPD), according to a study reported online in the journal Sleep.

Researchers followed 1,647 patients with confirmed COPD who were enrolled in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). SPIROMICS is a multicenter study funded by the National Heart, Lung, and Blood Institute and the COPD Foundation and is designed to evaluate COPD subpopulations, outcomes, and biomarkers. All participants in the study were current or former smokers with confirmed COPD.

COPD exacerbations over a 3-year follow-up period were compared against reported sleep quality. The researchers used the Pittsburgh Sleep Quality Index (PSQI), a combination of seven sleep measures, including sleep duration, timing of sleep, and frequency of disturbances. The higher the score, the worse the quality of sleep.

Individuals who self-reported having poor-quality sleep had a 25%-95% higher risk of COPD exacerbations, compared with those who reported good-quality sleep, according to the results.

There was a significant association between PSQI score and total and mean exacerbations in the unadjusted analysis (incidence rate ratios, 1.09; 95% confidence interval, 1.05-1.13) and the analysis adjusted for demographics, medical comorbidities, disease severity, medication usage, and socioeconomic environmental exposure (IRR, 1.08; 95% CI, 1.03-1.13).

In addition, the PSQI score was independently associated with an increased risk of hospitalization, with a 7% increase in risk of hospitalization with each 1-point increase in PSQI, according to the researchers.
 

Surprising findings

These findings suggest that sleep quality may be a better predictor of flare-ups than the patient’s history of smoking, according to the researchers.

“Among those who already have COPD, knowing how they sleep at night will tell me much more about their risk of a flare-up than knowing whether they smoked for 40 versus 60 years. … That is very surprising and is not necessarily what I expected going into this study. Smoking is such a central process to COPD that I would have predicted it would be the more important predictor in the case of exacerbations,” said lead study author Aaron Baugh, MD, a practicing pulmonologist, and a clinical fellow at the University of California, San Francisco, in a National Institutes of Health press release on the study.

The study findings were applicable to all races and ethnicities studied, however the results may be particularly relevant to Black Americans, Dr. Baugh indicated, because past studies have shown that Black Americans tend to have poorer sleep quality than other races and ethnicities. With poorer sleep linked to worse COPD outcomes, the current study may help explain why Black Americans as a group tend to do worse when they have COPD, compared with other racial and ethnic groups, the researchers suggested.

The study was supported by the National Institutes of Health and the COPD Foundation. SPIROMICS was supported by NIH and the COPD Foundation as well as numerous pharmaceutical and biotechnology companies. The authors reported no other financial disclosures.

Poor sleep quality was linked to an increased risk of life-threatening exacerbations in people with chronic obstructive pulmonary disease (COPD), according to a study reported online in the journal Sleep.

Researchers followed 1,647 patients with confirmed COPD who were enrolled in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). SPIROMICS is a multicenter study funded by the National Heart, Lung, and Blood Institute and the COPD Foundation and is designed to evaluate COPD subpopulations, outcomes, and biomarkers. All participants in the study were current or former smokers with confirmed COPD.

COPD exacerbations over a 3-year follow-up period were compared against reported sleep quality. The researchers used the Pittsburgh Sleep Quality Index (PSQI), a combination of seven sleep measures, including sleep duration, timing of sleep, and frequency of disturbances. The higher the score, the worse the quality of sleep.

Individuals who self-reported having poor-quality sleep had a 25%-95% higher risk of COPD exacerbations, compared with those who reported good-quality sleep, according to the results.

There was a significant association between PSQI score and total and mean exacerbations in the unadjusted analysis (incidence rate ratios, 1.09; 95% confidence interval, 1.05-1.13) and the analysis adjusted for demographics, medical comorbidities, disease severity, medication usage, and socioeconomic environmental exposure (IRR, 1.08; 95% CI, 1.03-1.13).

In addition, the PSQI score was independently associated with an increased risk of hospitalization, with a 7% increase in risk of hospitalization with each 1-point increase in PSQI, according to the researchers.
 

Surprising findings

These findings suggest that sleep quality may be a better predictor of flare-ups than the patient’s history of smoking, according to the researchers.

“Among those who already have COPD, knowing how they sleep at night will tell me much more about their risk of a flare-up than knowing whether they smoked for 40 versus 60 years. … That is very surprising and is not necessarily what I expected going into this study. Smoking is such a central process to COPD that I would have predicted it would be the more important predictor in the case of exacerbations,” said lead study author Aaron Baugh, MD, a practicing pulmonologist, and a clinical fellow at the University of California, San Francisco, in a National Institutes of Health press release on the study.

The study findings were applicable to all races and ethnicities studied, however the results may be particularly relevant to Black Americans, Dr. Baugh indicated, because past studies have shown that Black Americans tend to have poorer sleep quality than other races and ethnicities. With poorer sleep linked to worse COPD outcomes, the current study may help explain why Black Americans as a group tend to do worse when they have COPD, compared with other racial and ethnic groups, the researchers suggested.

The study was supported by the National Institutes of Health and the COPD Foundation. SPIROMICS was supported by NIH and the COPD Foundation as well as numerous pharmaceutical and biotechnology companies. The authors reported no other financial disclosures.

Poor sleep quality was linked to an increased risk of life-threatening exacerbations in people with chronic obstructive pulmonary disease (COPD), according to a study reported online in the journal Sleep.

Researchers followed 1,647 patients with confirmed COPD who were enrolled in the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). SPIROMICS is a multicenter study funded by the National Heart, Lung, and Blood Institute and the COPD Foundation and is designed to evaluate COPD subpopulations, outcomes, and biomarkers. All participants in the study were current or former smokers with confirmed COPD.

COPD exacerbations over a 3-year follow-up period were compared against reported sleep quality. The researchers used the Pittsburgh Sleep Quality Index (PSQI), a combination of seven sleep measures, including sleep duration, timing of sleep, and frequency of disturbances. The higher the score, the worse the quality of sleep.

Individuals who self-reported having poor-quality sleep had a 25%-95% higher risk of COPD exacerbations, compared with those who reported good-quality sleep, according to the results.

There was a significant association between PSQI score and total and mean exacerbations in the unadjusted analysis (incidence rate ratios, 1.09; 95% confidence interval, 1.05-1.13) and the analysis adjusted for demographics, medical comorbidities, disease severity, medication usage, and socioeconomic environmental exposure (IRR, 1.08; 95% CI, 1.03-1.13).

In addition, the PSQI score was independently associated with an increased risk of hospitalization, with a 7% increase in risk of hospitalization with each 1-point increase in PSQI, according to the researchers.
 

Surprising findings

These findings suggest that sleep quality may be a better predictor of flare-ups than the patient’s history of smoking, according to the researchers.

“Among those who already have COPD, knowing how they sleep at night will tell me much more about their risk of a flare-up than knowing whether they smoked for 40 versus 60 years. … That is very surprising and is not necessarily what I expected going into this study. Smoking is such a central process to COPD that I would have predicted it would be the more important predictor in the case of exacerbations,” said lead study author Aaron Baugh, MD, a practicing pulmonologist, and a clinical fellow at the University of California, San Francisco, in a National Institutes of Health press release on the study.

The study findings were applicable to all races and ethnicities studied, however the results may be particularly relevant to Black Americans, Dr. Baugh indicated, because past studies have shown that Black Americans tend to have poorer sleep quality than other races and ethnicities. With poorer sleep linked to worse COPD outcomes, the current study may help explain why Black Americans as a group tend to do worse when they have COPD, compared with other racial and ethnic groups, the researchers suggested.

The study was supported by the National Institutes of Health and the COPD Foundation. SPIROMICS was supported by NIH and the COPD Foundation as well as numerous pharmaceutical and biotechnology companies. The authors reported no other financial disclosures.

Sleep time may be a modifiable risk factor for cancer, according to a recent study from Japan.

The findings reveal that sleeping 10-plus hours may increase a woman’s risk of getting cancer and both men and women’s risk of dying from cancer. 

The researchers say their findings may help refine sleep recommendations in Japan, which currently advise working, middle-aged adults to sleep “as long as they can.”

Based on the new findings, a sleep duration of 6-8 hours for men and 6-9 hours for women “may be the safest” regarding cancer incidence and mortality risk among Japanese adults, the authors conclude.

The findings were published online in the International Journal of Cancer. 

The literature on sleep time and cancer risk is mixed. A trio of meta-analyses conducted between 2016 and 2019 found that long sleep duration, but not short, was associated with a slightly elevated risk of all cancer mortality in Asians.

A separate meta-analysis conducted in 2018 found that both short and long sleep durations were not related to cancer incidence. But in the stratified analysis, shorter sleep time was associated with 36% increased cancer risk among Asians.

To investigate further, the researchers pooled data from six population-based cohorts that included 271,694 adults – 126,930 men and 144,764 women – with 40,751 total incident cancer cases and 18,323 total cancer deaths during a follow-up lasting about 5.9 million person-years.

In the multivariable analysis, longer sleep duration was not associated with total cancer incidence in men. In women, however, sleeping 10 or more hours vs. 7 was associated with a 19% increased risk of cancer.

In addition, sleeping 10 or more hours was associated with an increased risk of dying from cancer in women (hazard ratio, 1.44) and men (HR, 1.18).

Sleeping for 5 hours or fewer, compared with 7, was not associated with cancer incidence and mortality. However, among postmenopausal women, shorter sleep durations did increase the risk of dying from cancer (HR, 1.15).

The authors highlight several strengths of the analysis, including a large sample size as well as stratification of the results by body mass index and menopause status, which has rarely been done in previous studies.

Limitations include self-reported sleep durations and lack of data on sleep quality. The researchers note that the mechanism by which sleep time may influence cancer incidence and mortality is unclear but likely to be complex and cancer site specific.

It’s also possible that reverse causation could explain associations between sleep duration and cancer occurrence and mortality – with pain from cancer, for instance, impairing sleep duration and quality. However, the sensitivity analysis found no evidence of reverse causality or other confounding factors.

Based on these findings, the researchers say sleep duration “may be an important variable to include in cancer incidence and mortality risk prediction models.”

The study had no specific funding. The authors declared no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Sleep time may be a modifiable risk factor for cancer, according to a recent study from Japan.

The findings reveal that sleeping 10-plus hours may increase a woman’s risk of getting cancer and both men and women’s risk of dying from cancer. 

The researchers say their findings may help refine sleep recommendations in Japan, which currently advise working, middle-aged adults to sleep “as long as they can.”

Based on the new findings, a sleep duration of 6-8 hours for men and 6-9 hours for women “may be the safest” regarding cancer incidence and mortality risk among Japanese adults, the authors conclude.

The findings were published online in the International Journal of Cancer. 

The literature on sleep time and cancer risk is mixed. A trio of meta-analyses conducted between 2016 and 2019 found that long sleep duration, but not short, was associated with a slightly elevated risk of all cancer mortality in Asians.

A separate meta-analysis conducted in 2018 found that both short and long sleep durations were not related to cancer incidence. But in the stratified analysis, shorter sleep time was associated with 36% increased cancer risk among Asians.

To investigate further, the researchers pooled data from six population-based cohorts that included 271,694 adults – 126,930 men and 144,764 women – with 40,751 total incident cancer cases and 18,323 total cancer deaths during a follow-up lasting about 5.9 million person-years.

In the multivariable analysis, longer sleep duration was not associated with total cancer incidence in men. In women, however, sleeping 10 or more hours vs. 7 was associated with a 19% increased risk of cancer.

In addition, sleeping 10 or more hours was associated with an increased risk of dying from cancer in women (hazard ratio, 1.44) and men (HR, 1.18).

Sleeping for 5 hours or fewer, compared with 7, was not associated with cancer incidence and mortality. However, among postmenopausal women, shorter sleep durations did increase the risk of dying from cancer (HR, 1.15).

The authors highlight several strengths of the analysis, including a large sample size as well as stratification of the results by body mass index and menopause status, which has rarely been done in previous studies.

Limitations include self-reported sleep durations and lack of data on sleep quality. The researchers note that the mechanism by which sleep time may influence cancer incidence and mortality is unclear but likely to be complex and cancer site specific.

It’s also possible that reverse causation could explain associations between sleep duration and cancer occurrence and mortality – with pain from cancer, for instance, impairing sleep duration and quality. However, the sensitivity analysis found no evidence of reverse causality or other confounding factors.

Based on these findings, the researchers say sleep duration “may be an important variable to include in cancer incidence and mortality risk prediction models.”

The study had no specific funding. The authors declared no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Sleep time may be a modifiable risk factor for cancer, according to a recent study from Japan.

The findings reveal that sleeping 10-plus hours may increase a woman’s risk of getting cancer and both men and women’s risk of dying from cancer. 

The researchers say their findings may help refine sleep recommendations in Japan, which currently advise working, middle-aged adults to sleep “as long as they can.”

Based on the new findings, a sleep duration of 6-8 hours for men and 6-9 hours for women “may be the safest” regarding cancer incidence and mortality risk among Japanese adults, the authors conclude.

The findings were published online in the International Journal of Cancer. 

The literature on sleep time and cancer risk is mixed. A trio of meta-analyses conducted between 2016 and 2019 found that long sleep duration, but not short, was associated with a slightly elevated risk of all cancer mortality in Asians.

A separate meta-analysis conducted in 2018 found that both short and long sleep durations were not related to cancer incidence. But in the stratified analysis, shorter sleep time was associated with 36% increased cancer risk among Asians.

To investigate further, the researchers pooled data from six population-based cohorts that included 271,694 adults – 126,930 men and 144,764 women – with 40,751 total incident cancer cases and 18,323 total cancer deaths during a follow-up lasting about 5.9 million person-years.

In the multivariable analysis, longer sleep duration was not associated with total cancer incidence in men. In women, however, sleeping 10 or more hours vs. 7 was associated with a 19% increased risk of cancer.

In addition, sleeping 10 or more hours was associated with an increased risk of dying from cancer in women (hazard ratio, 1.44) and men (HR, 1.18).

Sleeping for 5 hours or fewer, compared with 7, was not associated with cancer incidence and mortality. However, among postmenopausal women, shorter sleep durations did increase the risk of dying from cancer (HR, 1.15).

The authors highlight several strengths of the analysis, including a large sample size as well as stratification of the results by body mass index and menopause status, which has rarely been done in previous studies.

Limitations include self-reported sleep durations and lack of data on sleep quality. The researchers note that the mechanism by which sleep time may influence cancer incidence and mortality is unclear but likely to be complex and cancer site specific.

It’s also possible that reverse causation could explain associations between sleep duration and cancer occurrence and mortality – with pain from cancer, for instance, impairing sleep duration and quality. However, the sensitivity analysis found no evidence of reverse causality or other confounding factors.

Based on these findings, the researchers say sleep duration “may be an important variable to include in cancer incidence and mortality risk prediction models.”

The study had no specific funding. The authors declared no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

Hospital in Home (HIH) is the delivery of acute care services in a patient’s home as an alternative to hospitalization.¹ Compared with traditional inpatient care, HIH programs have been associated with reduced costs, as well as patient and caregiver satisfaction, diseasespecific outcomes, and mortality rates that were similar or improved compared with inpatient admissions.^1-4

The US Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and other hospital systems are increasingly adopting HIH models.^2-4 At the time of this writing, there were 12 HIH programs in VHA (personal communication, D. Cooper, 2/28/2022). In addition to physicians and nurses, the interdisciplinary HIH team may include a pharmacist, social worker, and registered dietitian nutritionist (RDN).^2,5 HIH programs have been shown to improve nutritional status as measured by the Mini Nutritional Assessment Score, but overall, there is a paucity of published information regarding the provision of nutrition care in HIH.⁶ The role of the RDN has varied within VHA. Some sites, such as the Sacramento VA Medical Center in California, include a distinct RDN position on the HIH team, whereas others, such as the Spark M. Matsunaga VA Medical Center in Honolulu, Hawaii, and the James A. Haley Veterans’ Hospital in Tampa, Florida, consult clinic RDNs.

Since HIH programs typically treat conditions for which diet is an inherent part of the treatment (eg, congestive heart failure [CHF]), there is a need to precisely define the role of the RDN within the HIH model.^2,3,7 Drawing from my experience as an HIH RDN, I will describe how the inclusion of an RDN position within the HIH team is optimal for health care delivery and how HIH practitioners can best utilize RDN services.

RDN Role in HIH Team

Delegating nutrition services to an RDN enhances patient care by empowering HIH team members to function at the highest level of their scope of practice. RDNs have been recognized by physicians as the most qualified health care professionals to help patients with diet-related conditions, such as obesity, and physicians also have reported a desire for additional training in nutrition.⁸ Although home-health nurses have frequently performed nutrition assessments and interventions, survey results have indicated that many nurses do not feel confident in teaching complex nutritional information^.9 In my experience, many HIH patients are nutritionally complex, with more than one condition requiring nutrition intervention. For example, patients may be admitted to HIH for management of CHF, but they may also have diabetes mellitus (DM), obesity, and low socioeconomic status. The HIH RDN can address the nutrition aspects of these conditions, freeing time for physicians and nurses to focus on their respective areas of expertise.^9,10 Moreover, the RDN can also provide dietary education to the HIH team to increase their knowledge of nutritional topics and promote consistent messaging to patients.

Including an RDN on the HIH team enables patients to have comprehensive, personalized nutrition care. Rather than merely offering generalized nutrition education, RDNs are trained to provide medical nutrition therapy (MNT), which has been shown to improve health outcomes and be cost-effective for conditions such as type 2 DM, chronic kidney disease, hypertension, and obesity.^10,11 In MNT, RDNs use the standardized 4-stepnutrition care process (NCP).¹² The Table shows examples of how the NCP can be applied in HIH settings. Furthermore, in my experience, MNT from an RDN also contributes to patient satisfaction. Subjective observations from my team have indicated that patients often express more confidence in managing their diets by the time of HIH discharge.

RDNs can guide physicians and pharmacists in ordering oral nutrition supplements (ONS). Within the VHA, a “food first” approach is preferred to increase caloric intake, and patients must meet specific criteria for prescription of an ONS.¹³ Furthermore, ONS designed for specific medical conditions (eg, chronic kidney disease) are considered nonformulary and require an RDN evaluation.¹³ Including an RDN on the HIH team allows this evaluation process to begin early in the patient’s admission to the program and ensures that provision of ONS is clinically appropriate and cost-effective.

Care Coordination

HIH is highly interdisciplinary. Team members perform their respective roles and communicate with the team throughout the day. RDNs can help monitor patients and alert physicians for changes in blood glucose, gastrointestinal concerns, and weight. This is especially helpful for patients who do not have a planned nursing visit on the day of an RDN evaluation. The HIH RDN can also collaborate with other team members to address patient needs. For example, for patients with limited financial resources, the HIH RDN can provide nutrition education regarding cooking on a budget, and the HIH social worker can arrange free or low-cost meal services.

Tips

When hiring an HIH RDN, seek candidates with experience in inpatient, outpatient, and home care settings. As a hybrid of these 3 areas, the HIH RDN position requires a unique combination of acute care skills and health coaching. Additionally, in my experience, the HIH RDN interacts more frequently with the HIH team than other RDN colleagues, so it is important that candidates can work independently and take initiative. This type of position would not be suitable for entry-level RDNs.

Stagger HIH team visits to prevent overwhelming the patient and caregivers. Early in our program, my team quickly learned that patients and caregivers can feel overwhelmed with too many home visits upon admission to HIH. After seeing multiple HIH team members the same day, they were often too tired to focus well on diet education during my visit. Staggering visits (eg, completing the initial nutrition assessment 1 day to 1 week after the initial medical and pharmacy visits) has been an effective strategy to address this problem. Furthermore, some patients prefer that the initial RDN appointment is conducted by telephone, with an inperson reassessment the following week. In my experience, HIH workflow is dynamic by nature, so it is crucial to remain flexible and accommodate individual patient needs as much as possible.

Dietary behavior change is a long-term process, and restrictive hospital diets can be challenging to replicate at home. In a hospital setting, clinicians can order a specialized diet (eg, low sodium with fluid restriction for CHF patients), whereas efforts to implement these restrictions in the home setting can be cumbersome and negatively impact quality of life.^7,14 Nevertheless, the effectiveness of medical treatment is compromised when patients do not adhere to dietary recommendations. Meal delivery services that offer specialized diets can be a useful resource for patients and caregivers who are unable to cook, and the HIH RDN can assist patients in ordering these services.

HIH patients may vary in terms of readiness to make dietary changes, and in addition to nutrition education, nutrition counseling is usually needed to effect behavior change. My team has found that consideration of the transtheoretical/ stages of change model can be a helpful approach. ¹⁵ The HIH RDN can tailor nutrition interventions to the patient’s stage of change. For example, for patients in the precontemplation stage, the HIH RDN would focus on providing information and addressing emotional aspects of dietary change. In contrast, for patients in the action stage of change, the HIH RDN might emphasize behavioral skill training and social support.¹⁵ Particularly for patients in the early stages of change, it may be unrealistic to expect full adoption of the recommended diet within the 30 days of the HIH program. However, by acknowledging the reality of the patient’s stage of change, the HIH RDN and team can then collaborate to support the patient in moving toward the next stage. Patients who are not ready for dietary behavior change during the 30 days of HIH may benefit from longer-term support, and the HIH RDN can arrange followup care with an outpatient RDN.

Conclusions

As the HIH model continues to be adopted across the VHA and other health care systems, it is crucial to consider the value and expertise of an RDN for guiding nutrition care in the HIH setting. The HIH RDN contributes to optimal health care delivery by leading nutritional aspects of patient care, offering personalized MNT, and coordinating and collaborating with team members to meet individual patient needs. An RDN can serve as a valuable resource for nutrition information and enhance the team’s overall services, with the potential to impact clinical outcomes and patient satisfaction.

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX

I enjoyed reading “How to identify balance disorders and reduce fall risk” (J Fam Pract. 2022;71:20-30) from the January/February issue. I was, however, disappointed to see that normal pressure hydrocephalus (NPH) was not discussed in the article or tables.

Recently, I took care of a 72-year-old patient who presented after multiple falls. In conjunction with Neurology, the presumptive diagnosis of Parkinson disease was made. However, the patient continued to experience a health decline that included cognitive changes, nocturia, and the classic “magnetic gait” of NPH (mnemonic for diagnosing this triad of symptoms: weird, wet, wobbly). The presumptive diagnosis was then changed when the results of a fluorodopa F18 positron emission tomography scan (also known as a DaT scan) returned as normal, essentially excluding the diagnosis of Parkinson disease.

The patient has since seen a dramatic improvement in gait and cognitive and urinary symptoms following a high-volume lumbar puncture and placement of a ventriculoperitoneal shunt. 

This case demonstrates the importance of considering NPH in the differential diagnosis for patients with balance disorders. Prompt diagnosis and management can result in a variable, but at times dramatic, reversal of symptoms. 

Ernestine Lee, MD, MPH
Austin, TX