Saturday, June 21, 2014

Vietnam Veterans, HCV, and Our Troubled VA

Vietnam Veterans, HCV, and Our Troubled VA 

Happy Saturday everyone, hopefully you have time to catch up on some weekend reading. Don't forget to check out June's index of Hepatitis Newsletters, and hot topics.

Today we offer an update on our horrific VA system, recent data on HCV risk factors pertaining to Vietnam veterans, and a few links to other problems at VA medical facilities.

We begin with the study assessing HCV risk factors among U.S. Military veterans from the Vietnam era. The purpose of the study was to investigate HCV risk factors among Vietnam veterans compared to nonveterans. The authors noted past studies mostly took place within the VA system, this study looked at 4,636 HCV patients who received care outside the VA.  The study suggested;  "Vietnam War era veterans did not report a higher prevalence of common hepatitis C risk factors — including injection drug use — compared with nonveterans, but they may have faced risk factors specific to their military service." The paper was published in the Journal of Community Health last April and featured in the June issue of Healio's "HCV Next"

These findings are important on so many levels, it finally illustrates to the VA that many Vietnam veterans were infected through known military risk factors. The social stigma of living with HCV is difficult enough, but even more so for our Vietnam veterans. Sadly, for decades, veterans have reported the VA presumed they were infected through intravenous drug use - unless they could prove otherwise. 

Other risk factors associated with military service include; emergency battle-related transfusions using unscreened blood, exposure to blood/body fluid in the field, or blood exposure through the multidose vaccination process, tattoos, sharing razors or non-sterile instruments. 

Transmission Of HCV
Not until 1990 was a screening test for hepatitis C developed, many people were infected with HCV by receiving blood products or a transfusion before 1990-1992. During this time approximately 30,000 people received letters from the Red Cross saying that they were infected with hepatitis C through contaminated blood. Officials estimated two hundred and fifty thousand people were at risk through earlier blood transfusions in the 1980's.

Provided below we have a few links to previous problems at VA medical facilities, and an interesting 2013 video from The Daily Show, with comedian Jon Stewart discussing the VA, legionnaires outbreak, exposure to hepatitis and the failure to monitor mental health patients at a few hospitals. Finally, the study; Vietnam era vets may not be at higher risk for HCV than nonvets, and an update from CNN on our troubled VA health care system. 


June 2011 
VA hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga. 
First VA colonoscopy case goes to trial after Miami vet contracted hepatitis C
A Coral Gables U.S. Air Force vet who says he contracted hepatitis C from a colonoscopy done at the Miami VA hospital with improperly cleaned equipment will press his claim in a Miami federal court.
More than 11,000 U.S. veterans received colonoscopies with improperly cleaned equipment at VA hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga., between 2004 and 2009. Of the veterans who had the procedure at the three facilities, five have tested positive for HIV, 25 for hepatitis C and eight for hepatitis B. In Miami, 11 additional suits charging emotional distress have been settled out of court for undisclosed amounts, the U.S. Attorney’s office said. Nine malpractice suits have been filed in Tennessee. Officials in Georgia couldn’t say how many have been filed there. None has gone to trial until now.

Related - June 2012
Hepatitis B-Court ruled against Tennessee veteran who claims he contracted HBV at Murfreesboro VA hospital
In the latest legal setback, a federal appeals court has ruled against a Tennessee veteran who claims he contracted hepatitis B after employees at the Murfreesboro VA hospital negligently failed to properly clean colonoscopy equipment. The ruling could have an impact on similar lawsuits against the VA.

April 2011
John Cochran Veterans Medical Center in St. Louis, MO
Ohio panel wants more VA tests for clinic patients
The lack of "adherence to sterilization practices" or "inadequate practices" at VA dental center was reported in 2011. During 2009 to 2010 notification letters sent to 1,812 veterans who may have been exposed to hepatitis B, hepatitis C and HIV; when a breach in protocol instrument processing took place at the John Cochran Veterans Medical Center in St. Louis, MO. The Associated Press reported in March 2011 that most of the 1,812 veterans potentially exposed have been tested with no infections connected to the dental clinic.

Of Interest
Video: Daily Show Takes on the VA 
In this 2013 video, talk show host Jon Stewart begins with checking on the progress of the VA's backlogged benefits, however, instead the comedian discovered problems at numerous VA hospitals.

Vietnam era vets may not be at higher risk for HCV than nonvets
Boscarino JA. J Community Health. 2014;doi:10.1007/s10900-014-9863-5.

Vietnam War era veterans did not report a higher prevalence of common hepatitis C risk factors — including injection drug use — compared with nonveterans, but they may have faced risk factors specific to their military service, according to new study data.

“Vietnam era veterans may have other HCV exposure risk factors in their history, other than injection drug abuse,” study researcher Joseph A. Boscarino, PhD, MPH, a senior scientist at Geisinger Health System Center for Health Research in Danville, Pa., told Infectious Disease News.

“Most important, they do not appear to have higher rates of injection drug abuse than comparable nonveterans. Also, a number of these vets report they got HCV through their military service during the Vietnam War era. We don't know if this is true or not, and more research may be required to answer this question more definitively.”

Joseph A. Boscarino, MD, MPH
Joseph A. Boscarino
Previous studies suggest that Vietnam era veterans have higher rates of HCV infection, which is attributed to a greater prevalence of injection drug use. However, the researchers said most of these studies have been conducted among patients in the Department of Veteran Affairs health care system, which most veterans do not use.

Patients that use the VA health care system also tend to be different demographically.

To assess HCV risk factors among Vietnam era veterans vs. nonveterans, Boscarino and colleagues surveyed 4,636 HCV patients who received care in four health care systems outside the VA. Among the male respondents (n=2,638), 22.5% served in the US military at some point from 1964 to 1975. These Vietnam era veterans were more likely to be older (P<.001), more educated (P<.001), less often foreign born (P=.009), and more often married (P<.001) vs. nonveterans.

Vietnam era veterans actually had a lower prevalence of injection drug use compared with nonveterans (54% vs. 58%; P=.16). Other common risk factors for HCV infection, including occupational risk factors (P=.18), medical procedures (P=.61) and blood transfusions or organ transplantations (P=.94), were not more common among Vietnam era veterans. The researchers found that nonveterans were more likely than veterans to report sex with men (P=.013) as a risk factor for infection, but the prevalence was low (2.4% vs. 0.6%).

Analyses indicated that Vietnam era veterans were more likely to report “other” risk factors as the source of their infection (P<.001) — namely, exposure to vaccinations during their military service. The researchers said that during the Vietnam War era, service members received multiple injections, typically with pneumatic injectors, as they moved through vaccination lines, and bleeding was not uncommon. This method of vaccination was later phased out by the military.

Although more research is needed, Boscarino said clinicians can play an important role in the management of HCV in veterans.

“Clinicians need to be aware that the VA will provide disability compensation for vets for HCV, if the vet can submit a supportable claim to the VA for HCV infection related to military service,” Boscarino said.

“In some cases, clinicians may be able to help vets submit a claim to the VA related to their particular case. Ultimately, this may be difficult because these potential exposures occurred decades ago, but the veterans will appreciate this support from clinicians.” – John Schoen

Disclosure: See the study for a full list of financial disclosures.
Source - Healio

Performance reviews at troubled VA showed no bad senior managers
By Tom Cohen and Curt Devine, CNN
updated 10:08 PM EDT, Fri June 20, 2014

Washington (CNN) -- No matter what you call it -- bonuses, incentives, market or performance pay -- the Department of Veterans Affairs gave out a lot to senior managers in recent years despite sometimes deadly waits for health care and other problems faced by American veterans.

A top VA official confirmed to a congressional committee on Friday that 78% of VA senior managers qualified for extra pay or other compensation in fiscal year 2013 by receiving ratings of "outstanding" or "exceeds fully successful," and that all 470 of them got ratings of "fully successful" or better.

Such widespread laudatory performance appraisals occurred shortly before CNN started reporting in November how veterans waited excessive periods for VA health care, with some dying in the process. The VA has acknowledged 23 deaths nationwide due to delayed care.

In Phoenix, CNN reported in April that the VA used fraudulent record-keeping -- including an alleged secret list -- that covered up the waiting periods.

A fatal wait: Veterans languish and die on a VA hospital's secret list

That didn't stop the head of the Phoenix VA medical center, Sharon Helman, from getting an $8,500 bonus last year.

Helman's bonus got rescinded earlier this year after the VA controversy made headlines. She was placed on administrative leave but continues to receive her salary, said Gina Farrisee, the VA assistant secretary for human resources and administration, at a House Veterans' Affairs Committee hearing.

Questionable bonuses

Panel chairman Jeff Miller, a Florida Republican, cited numerous examples of what he characterized as unwarranted bonuses to VA officials overseeing a department with such problems in recent years:

• The medical center director in Dayton, Ohio, receiving a bonus exceeding $10,000 despite an investigation of veterans getting exposed to hepatitis B and C at the facility;

• The former director of the VA regional office in Waco, Texas, getting more than $53,000 in bonuses when the average processing time for disability claims increased to what Miller called "inexcusable levels."

• The director of the Pittsburgh health care system getting a top performance review and a regional director getting a $63,000 bonus despite a legionella outbreak in the Pittsburgh VA health care system that led to six patient deaths.

"To the average American, $63,000 is considered to be a competitive annual salary, not a bonus," Miller said.

Farrisee offered administrative explanations about the bonus system that did little to satisfy committee members. In particular, the Helman case in Phoenix got a lot of attention, with legislators from both parties asking how it could happen.

She explained how the bonus should never have been given because Helman was being investigated in connection with the problems at the Phoenix VA facility, and therefore the extra money was eligible to be rescinded.

Can't go back

However, Farrisee said in almost all other cases, a performance rating and resulting bonus can't be rescinded later on.

"If we knew what we knew today at that time, it is unlikely that their performance would have reflected what it reflected at the time the reports were written," she said when asked by Miller about going back to change the performance review results.

However, "you cannot go back and change a rating once it has been issued to an employee as the final rating," Farrisee said, adding that was the law rather than a government rule.

An exasperated Miller called it a law that needed to change as part of an overhaul of a culture throughout the VA motivated more by performance bonuses than serving veterans.

"We can't keep doing it the way it's been being done," he said, to which Farrisee responded: "I concur, Mr. Chairman."

The controversy, with multiple investigations and increasing revelations of problems with newly returned veterans getting care on a timely basis, caused retired Army Gen. Eric Shinseki to resign on May 30 as Veterans Affairs secretary.

Fear kept the VA scandal

His successor, interim Secretary Sloan Gibson, has ruled out any bonuses for senior managers in 2014 as part of initial steps intended to get more immediate care for hundreds of thousands of waiting veterans.

Updated figures

Earlier this week, an updated audit revealed about 177,000 veterans were still waiting at least two months for an appointment at VA medical centers.

Gibson said some of the delays on the audit update appeared worse than previously reported because hospital administrators were beginning to use proper scheduling procedures that accurately reflected the number of veterans waiting.

For example, the update showed more than 43,000 veterans waiting longer than 120 days for an appointment, compared to 13,000 listed earlier this month.

According to Gibson, more appointments have been added, but some VA hospitals lack the capacity to see patients quickly, which also contributed to a spike in the figures.

The VA has reached out to 70,000 veterans waiting for appointments in order to get them into clinics, he said.

At this point, the VA's Office of Inspector General is investigating 69 facilities for allegations that administrators altered appointment data or used secret waiting lists to make patient wait times appear shorter in order to earn financial bonuses.

Farrisee said Friday that schedulers sought to meet their performance goal -- and therefore qualify for bonuses -- by showing veterans got appointments within 14 days.

An internal audit by the VA called that 14-day goal implemented under Shinseki's leadership unattainable and reported 13% of schedulers were instructed to manipulate data in some form.

Gibson has eliminated the 14-day target for the Veterans Health Administration, which has more than 1,700 facilities that serve almost 9 million veterans each year.

Go the VA website

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