Editorials from VA Research Scientists
Sharing connections in times of distress
Dr. Leonie Heyworth is an internist and health services researcher with the VA San Diego Healthcare System in La Jolla, California. She is also VA's national synchronous telehealth lead for the Office of Connected Care. In an editorial published in JAMA, she recounts her experience treating a Vietnam Veteran in Texas—via telehealth—who had nearly been stranded in the flood waters of Hurricane Harvey. The storm, a Category 4 hurricane, hit the Houston area in 2017—causing more than $100 billion in damage from catastrophic flooding.
As VA launched its emergency response system to help Veterans impacted by Hurricane Harvey, it also included for the first time a telehealth component. Virtual capabilities were established at two mega-shelters and four community-based outpatient clinics. In addition to medical services, more than 100 social workers volunteered their services to Veterans and community members who were in need of counseling.
Despite concerns about the isolating effects of technology, writes Heyworth, it is important to acknowledge how well-suited it is in connecting patients who don't have access to health care with remote providers. In the case of Heyworth's patient, she was able to prescribe an antibiotic to treat a diabetic ulcer on his foot, which had been contaminated by dirty flood waters. During a follow-up telephone call, he told Heyworth that he felt much better and was able to bring his wife to her chemotherapy appointment.
"In health care, telehealth offers the vital opportunity to directly connect caregivers to those most in need of care and those most lacking access to that care," writes Heyworth. "In the case of natural disasters, telehealth has the unique capacity to scale operations and offer quick access to primary care, mental health, or specialty services."
* To find out more about VA's use of telehealth in emergency responses to natural disasters, read "Telehealth proves its worth, saving life and limb in the aftermath of hurricane" and "VHA's telehealth emergency medicine use holiday to test systems, prepare for emergency responses."
'Bringing invisible partners in care out of the shadows'
As vital as family caregivers are to disabled Americans, there are limited resources to help these caregivers financially, says Dr. Courtney Van Houtven. And, if they do receive financial support, she adds, there will likely be unintended consequences that should be considered. Van Houtven is a VA researcher with the HSR&D Center for Health Services Research in Primary Care, in Durham, North Carolina. In an online editorial published ahead of print in Health Services Research, Van Houtven writes about the lack of strong evidence-based research on the effects of removing family caregivers from the workforce by supplying financial support.
In Europe, she writes, there are multiple systems in place to support family caregiving. But, in the U.S. there isn't a single support system that all caregivers can utilize. Resources are fragmented. So far, only three states in the U.S. have implemented paid family medical leave: California, New Jersey, and Rhode Island. New York will offer similar benefits starting in 2018. In these states, family medical leave is funded through employee-paid payroll taxes.
In the case of U.S. Veterans, there is a national support program for caregivers of Veterans that offers training and respite care. For caregivers of post 9/11 Veterans who have significant limitations and need help with activities of daily living, there are more robust benefits such as a stipend and health insurance.
However, if family or friends elect to step out of the workforce in order to be a full-time caregiver, says Van Houtven, they may face future economic insecurity by losing or reducing their Social Security and Medicare benefits.
*Listen to Dr. Houtven talk about her research evaluating the VA CARES caregiver support program.
'Suggested paths to fixing the opioid crisis'
In an editorial published in JAMA Network, Birmingham, Alabama, VA researcher Dr. Stefan Kertesz and his coauthor Dr. Jeffrey Samet suggest there are no easy answers to addressing the national opioid crisis. While it is prudent to follow the current path of opioid prescription controls that look at limiting the dose and duration of prescriptions, that alone will not address the full problem, they say. They recommend taking a broader view, one that recognizes the importance of addiction care that is integrated into the primary care setting.
The authors point to the disturbing findings from a study led by Dr. Tara Gomes, also published in JAMA Network. The researchers found that the percentage of deaths attributable to opioids in the U.S. increased by nearly 300 percent during the period 2001–2016. Young people were hit the hardest—in 2016, 20 percent of all deaths among adults age 24 to 35 years involved opioids.
The scope of the opioid problem requires a different treatment approach, say the authors. They believe that addiction care should become part of "mainstream medicine." To start, physicians and other care providers should be trained in the use of medications like methadone and buprenorphine to help patients stop taking opioids. At present, methadone can be prescribed only in a licensed clinic. The authors also recommend the use of complementary services like psychotherapy and housing assistance to help patients successfully stop opioid use.
"Medical efforts to address substance use disorders, and in particular opioid use disorders, should grow within primary care and be allied with the addiction subspecialty care system," write the authors. "Accessible, effective medical care that routinely includes medications should be the standard to which clinical practice is held."