Federal Practitioner

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

Military medical personnel rely on individual critical tasks lists (ICTLs) to maintain proficiency in essential medical skills during deployments. However, sustaining these competencies in a low-casualty operational setting presents unique challenges. Traditional training methods, such as lectures or simulations outside operational contexts, may lack engagement and fail to replicate the stressors of real-world scenarios. Previous research has emphasized the importance of continuous medical readiness training in austere environments, highlighting the need for innovative approaches.^1,2

The Litter Olympics was developed as an in-theater training exercise designed to enhance medical readiness, foster interdisciplinary teamwork, and incorporate physical exertion into skill maintenance. By requiring teams to carry a patient litter through multiple “events,” the exercise reinforced teamwork within a medical readiness-focused series inspired by an Olympic decathlon. This article discusses the feasibility, effectiveness, and potential impact of the Litter Olympics as a training tool for maintaining ICTLs in a deployed environment.

Program

The Litter Olympics were implemented at a Role 3 medical facility in Baghdad, Iraq, where teams composed of individuals from military occupational specialties (MOSs) and areas of concentration (AOCs) participated. Role 3 facilities provide specialty surgical and critical care capabilities, enabling a robust medical training environment.³ The event was designed to reflect the interdisciplinary nature of deployed medical teams and incorporated hands-on training stations covering critical medical skills such as traction splinting, spinal precautions, patient movement, hemorrhage control, airway management, and tactical evacuation procedures.

Tasks were selected based on their relevance to deployed medical care and their inclusion in ICTLs, ensuring alignment with mission-essential skills. Participants were evaluated on task completion, efficiency, and teamwork by experienced medical personnel. Postexercise surveys assessed skill improvement, confidence levels, and areas for refinement. Future studies should incorporate structured performance metrics, such as pre- and postevent evaluations, to quantify proficiency gains (Table 1).

Five mixed MOS/AOC teams participated in the event, completing the exercise in an average time of 50 minutes (Table 2). Participants reported increased confidence in performing ICTs, particularly in patient movement, hemorrhage control, and airway management. The interdisciplinary nature of the teams facilitated peer teaching and cross-training, allowing individuals to better understand each other’s roles and responsibilities. This mirrors findings in previous studies on predeployment training that emphasize the importance of collaborative, hands-on learning.⁴ The physical aspect of the exercise was well received, as it simulated operational conditions and reinforced endurance in high-stress environments. Some tasks, such as cricothyroidotomy and satellite radio setup, required additional instruction, highlighting areas for improvement in future iterations.

Discussion

The Litter Olympics provide a dynamic alternative to traditional classroom instruction by integrating realistic, scenario-based training. However, several limitations were identified. The most significant was the lack of formalized outcome metrics. While qualitative feedback was overwhelmingly positive, no structured performance assessment tool, such as pre- and postevent skill evaluations, was used. Future studies should incorporate objective measures of competency to strengthen the evidence base for this training model. Additionally, participant feedback suggested that more structured debriefing sessions postexercise would enhance learning retention and provide actionable insights for future program modifications.

Another consideration is the scalability and adaptability of the exercise. While effective in a Role 3 setting, modifications may be required for smaller units or lower levels of care. Future iterations could adapt the format for Role 1 or 2 environments by reducing the number of stations while preserving the core training elements. Furthermore, the event relied on access to specialized personnel and equipment, which may not always be feasible in austere settings. Developing a streamlined version focusing on essential tasks could improve accessibility and sustainability across different operational environments.

Participants expressed a preference for this hands-on, competitive training model over traditional didactic instruction. However, further research should compare skill retention rates between the Litter Olympics and other training modalities to validate effectiveness. While peer teaching was a notable strength of the event, structured mentorship from senior medical personnel could further enhance skill acquisition and reinforce best practices.

Conclusions

The Litter Olympics present a reproducible, engaging, and effective method for sustaining medical readiness in a deployed Role 3 setting. By fostering interdisciplinary collaboration and incorporating physical and cognitive stressors, it enhances both individual and team preparedness. Future research should develop standardized, measurable outcome assessments, explore application in diverse deployment settings, and optimize scalability for broader military medical training programs. Standardized evaluation tools should be developed to quantify performance improvements, and the training model should be expanded to include lower levels of care and nonmedical personnel. Structured debriefing sessions would also provide valuable insight into lessons learned and potential refinements. By integrating these enhancements, the Litter Olympics can serve as a cornerstone for maintaining operational medical readiness in deployed environments.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

The Veterans Health Administration (VHA) has continued to advance its understanding and treatment of chronic pain. The VHA National Pain Management Strategy emphasizes the significance of the social context of pain while underscoring the importance of self-management.¹ This established strategy ensures that all veterans have access to the appropriate pain care in the proper setting.² VHA has instituted a stepped care model of pain management, delineating the domains of primary care, secondary consultative services, and tertiary care.³ This directive emphasized a biopsychosocial approach to pain management to prioritize the relationship between biological, psychological, and social factors that influence how veterans experience pain and should commensurately influence how it is managed.

The VHA Office of Patient-Centered Care and Cultural Transformation implemented the Whole Health System of Care as part of the Comprehensive Addiction and Recovery Act, which included a VHA directive to expand pain management.^4,5 Reorientation within this system shifts from defining veterans as passive care recipients to viewing them as active partners in their own care and health. This partnership places additional emphasis on peer-led explorations of mission, aspiration, and purpose.⁶

Peer-led groups, also known as mutual aid, mutual support, and mutual help groups, have historically been successful for patients undergoing treatment for substance use disorders (eg, Alcoholics Anonymous).⁷ Mutual help groups have 3 defining characteristics. First, they are run by participants, not professionals, though the latter may have been integral in the founding of the groups. Second, participants share a similar problem (eg, disease state, experience, disposition). Finally, there is a reciprocal exchange of information and psychological support among participants.^8,9 Mutual help groups that address chronic pain are rare but becoming more common.^10-12 Emerging evidence suggests a positive relationship between peer support and improved well-being, self-efficacy, pain management, and pain self-management skills (eg, activity pacing).^13-15

Storytelling as a tool for healing has a long history in indigenous and Western medical traditions.^16-19 This includes the treatment of chronic disease, including pain.^20,21 The use of storytelling in health care overlaps with the role it plays within many mutual help groups focused on chronic disease treatment.²² Storytelling allows an individual to share their experience with a disease, and take a more active role in their health, and facilitate stronger bonds with others.²² In effect, storytelling is not only important to group cohesion—it also plays a role in an individual’s healing.

Vet-to-Vet

The VHA Office of Rural Health funds Vet-to-Vet, a peer-to-peer program to address limited access to care for rural veterans with chronic pain. Similar to the VHA National Pain Management Strategy, Vet-to-Vet is grounded in the significance of the social context of pain and underscores the importance of self-management.¹ The program combines pain care, mutual help, and storytelling to support veterans living with chronic pain. While the primary focus of Vet-to-Vet is rural veterans, the program serves any veteran experiencing chronic pain who is isolated from services, including home-bound urban veterans.

Following mutual help principles, Vet-to-Vet peer facilitators lead weekly online drop-in meetings. Meetings follow the general structure of reiterating group ground rules and sharing an individual pain story, followed by open discussions centered on well-being, chronic pain management, or any topic the group wishes to discuss. Meetings typically end with a mindfulness exercise. The organizational structure that supports Vet-to-Vet includes the implementation support team, site leads, Vet-to-Vet peer facilitators, and national partners (Figure 1).

Implementation Support Team

The implementation support team consists of a principal investigator, coinvestigator, program manager, and program support specialist. The team provides facilitator training, monthly community practice sessions for Vet-to-Vet peer facilitators and site leads, and weekly office hours for site leads. The implementation support team also recruits new Vet-to-Vet sites; potential new locations ideally have an existing whole health program, leadership support, committed site and cosite leads, and ≥ 3 peer facilitator volunteers.

Site Leads

Most site and cosite leads are based in whole health or pain management teams and are whole health coaches or peer support specialists. The site lead is responsible for standing up the program and documenting encounters, recruiting and supporting peer facilitators and participants, and overseeing the meeting. During meetings, site leads generally leave their cameras off and only speak when called into the group; the peer facilitators lead the meetings. The implementation support team recommends that site leads dedicate ≥ 4 hours per week to Vet-to-Vet; 2 hours for weekly group meetings and 2 hours for documentation (ie, entering notes into the participants’ electronic health records) and supporting peer facilitators and participants. Cosite lead responsibilities vary by location, with some sites having 2 leads that equally share duties and others having a primary lead and a colead available if the site lead is unable to attend a meeting.

Vet-to-Vet Peer Facilitators

Peer facilitators are the core of the program. They lead meetings from start to finish. Like participants, they also experience chronic pain and are volunteers. The implementation support team encourages sites to establish volunteer peer facilitators, rather than assigning peer support specialists to facilitate meetings. Veterans are eager to connect and give back to their communities, and the Vet-to-Vet peer facilitator role is an opportunity for those unable to work to connect with peers and add meaning to their lives. Even if a VHA employee is a veteran who has chronic pain, they are not eligible to serve as this could create a service provider/service recipient dynamic that is not in the spirit of mutual help.

Vet-to-Vet peer facilitators attend a virtual 3-day training held by the implementation support team prior to starting. These training sessions are available on a quarterly basis and facilitated by the Vet-to-Vet program manager and 2 current peer facilitators. Training content includes established whole health facilitator training materials and program-specific storytelling training materials. Once trained, peer facilitators attend storytelling practice sessions and collaborate with their site leads during weekly meetings.

Participants

Vet-to-Vet participants find the program through direct outreach from site leads, word of mouth, and referrals. The only criteria to join are that the individual is a veteran who experiences chronic pain and is enrolled in the VHA (site leads can assist with enrollment if needed). Participants are not required to have a diagnosis or engage in any other health care. There is no commitment and no end date. Some participants only come once; others have attended for > 3 years. This approach is intended to embrace the idea that the need for support ebbs and flows.

National Partners

The VHA Office of Rural Health provides technical support. The Center for Development and Civic Engagement onboards peer facilitators as VHA volunteers. The Office of Patient-Centered Care and Cultural Transformation provides national guidance and site-level collaboration. The VHA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program supports site recruitment. In addition to the VHA partners, 4 veteran evaluation consultants who have experience with chronic pain but do not participate in Vet-to-Vet meetings provide advice on evaluation activities, such as question development and communication strategies.

Evaluation

This evaluation shares preliminary results from a pilot evaluation of the Rocky Mountain Regional VA Medical Center (RMRVAMC) Vet-to-Vet group. It is intended for program improvement, was deemed nonresearch by the Colorado Multiple Institutional Review Board, and was structured using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.²³ This evaluation focused on capturing measures related to reach and effectiveness, while a forthcoming evaluation includes elements of adoption, implementation, and maintenance.

In 2022, 16 Vet-to-Vet peer facilitators and participants completed surveys and interviews to share their experience. Interviews were recorded, transcribed, and coded in ATLAS.ti. A priori codes were based on interview guide questions and emergent descriptive codes were used to identify specific topics which were categorized into RE-AIM domains, barriers, facilitators, what participants learned, how participants applied what they learned to their lives, and participant reported outcomes. This article contains high-level findings from the evaluation; more detailed results will be included in the ongoing evaluation.

Results

The RMRVAMC Vet-to-Vet group has met weekly since April 2022. Four Vet-to-Vet peer facilitators and 12 individuals participated in the pilot Vet-to-Vet group and evaluation. The mean age was 62 years, most were men, and half were married. Most participants lived in rural areas with a mean distance of 125 miles to the nearest VAMC. Many experienced multiple kinds of pain, with a mean 4.5 on a 10-point scale (bothered “a lot”). All participants reported that they experienced pain daily.

Participation in Vet-to-Vet meetings was high; 3 of 4 peer facilitators and 7 of 12 participants completed the first 6 months of the program. In interviews, participants described the positive impact of the program. They emphasized the importance of connecting with other veterans and helping one another, with one noting that opportunities to connect with other veterans “just drops off a lot” (peer facilitator 3) after leaving active duty.

Some participants and Vet-to-Vet peer facilitators outlined the content of the sessions (eg, learning about how pain impacts the body and one’s family relationships) and shared the skills they learned (eg, goal setting, self-advocacy) (Table). Most spoke about learning from one another and the power of sharing stories with one peer facilitator sharing how they felt that witnessing another participant’s story “really shifted how I was thinking about things and how I perceived people” (peer facilitator 1). 

Participants reported several ways the program impacted their lives, such as learning that they could get help, how to get help, and how to overcome the mental aspects of chronic pain. One veteran shared profound health impacts and attributed the Vet-to-Vet program to having one of the best years of their life. Even those who did not attend many meetings spoke of it positively and stated that it should continue so others could try (Table).

From January 2022 to September 2025, > 80 veterans attended ≥ 1 meeting at RMRVAMC; 29 attended ≥ 1 meeting in the last quarter. There were > 1400 Vet-to-Vet encounters at RMRVAMC, with a mean (SD) of 14.2 (19.2) and a median of 4.5 encounters per participant. Half of the veterans attend ≥ 5 meetings, and one-third attended ≥ 10 meetings.

Since June 2023, 15 additional VHA facilities launched Vet-to-Vet programs. As of October 2025, > 350 veterans have participated in ≥ 1 Vet-to-Vet meeting, totaling > 4500 Vet-to-Vet encounters since the program’s inception (Figure 2).

Challenges

The RMRVAMC site and cosite leads are part of the national implementation team and dedicate substantial time to developing the program: 40 and 10 hours per week, respectively. Site leads at new locations do not receive funding for Vet-to-Vet activities and are recommended to dedicate only 4 hours per week to the program. Formally embedding Vet-to-Vet into the site leads’ roles is critical for sustainment.

The Vet-to-Vet model has changed. The initial Vet-to-Vet cohort included the 6-week Taking Charge of My Life and Health curriculum prior to moving to the mutual help format.²⁴ While this curriculum still informs peer facilitator training, it is not used in new groups. It has anecdotally been reported that this change was positive, but the impact of this adaptation is unknown.

This evaluation cohort was small (16 participants) and initial patient reported and administrative outcomes were inconclusive. However, most veterans who stopped participating in Vet-to-Vet spoke fondly of their experiences with the program.

CONCLUSIONS

Vet-to-Vet is a promising new initiative to support self-management and social connection in chronic pain care. The program employs a mutual help approach and storytelling to empower veterans living with chronic pain. The effectiveness of these strategies will be evaluated, which will inform its continued growth. The program's current goals focus on sustainment at existing sites and expansion to new sites to reach more rural veterans across the VA enterprise. While Vet-to-Vet is designed to serve those who experience chronic pain, a partnership with the Office of Whole Health has established goals to begin expanding this model to other chronic conditions in 2026.

Due to the underlying mechanism of atrial fibrillation (Afib), clots can form within the left atrial appendage. Clots that become dislodged may lead to ischemic stroke and possibly death. The 2023 guidelines for atrial fibrillation from the American College of Cardiology and American Heart Association recommend anticoagulation therapy for patients with an Afib diagnosis and a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke/vascular disease, age 65 to 74 years, and female sex) score pertinent for ≥ 1 non–sex-related factor (score ≥ 2 for women; ≥ 1 for men) to prevent stroke-related complications. The CHA₂DS₂-VASc score is a 9-point scoring tool based on comorbidities and conditions that increase risk of stroke in patients with Afib. Each value correlates to an annualized stroke risk percentage that increases as the score increases.

In clinical practice, patients meeting these thresholds are indicated for anticoagulation and are considered for indefinite use unless ≥ 1 of the following conditions are present: bleeding risk outweighs the stroke prevention benefit, Afib is episodic (< 48 hours) or a nonpharmacologic intervention, such as a left atrial appendage occlusion (LAAO) device is present.¹

In patients with a diagnosed venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, anticoagulation is used to treat the current thrombosis and prevent embolization that can ultimately lead to death. The 2021 guideline for VTE from the American College of Chest Physicians identifies certain risk factors that increase risk for VTE and categorizes them as transient or persistent. Transient risk factors include hospitalization > 3 days, major trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel > 8 hours. Persistent risk factors include malignancy, thrombophilia, and certain medications.

The guideline recommends therapy durations based on event frequency, the presence and classification of provoking risk factors, and bleeding risk. As the risk of recurrent thrombosis and other potential complications is greatest in the first 3 to 6 months after a diagnosed event, at least 3 months anticoagulation therapy is recommended following VTE diagnosis. At the 3-month mark, all regimens are suggested to be re-evaluated and considered for extended treatment duration if the event was unprovoked, recurrent, secondary to a persistent risk factor, or low bleed risk.²Anticoagulation is an important guideline-recommended pharmacologic intervention for various disease states, although its use is not without risks. The Institute for Safe Medication Practices has classified oral anticoagulants as high-alert medications. This designation was made because anticoagulant medications have the potential to cause harm when used or omitted in error and lead to life-threatening bleed or thrombotic complications.³Anticoagulation stewardship ensures that anticoagulation therapy is appropriately initiated, maintained, and discontinued when indicated. Because of the potential for harm, anticoagulation stewardship is an important part of Afib and VTE management. Pharmacists can help verify and evaluate anticoagulation therapies. Research suggests that pharmacist-led anticoagulation stewardship efforts may play a role in ensuring safer patient outcomes.⁴The purpose of this quality improvement (QI) study was to implement pharmacist-led anticoagulation stewardship practices at Veterans Affairs Phoenix Health Care System (VAPHCS) to identify veterans with Afib not currently on anticoagulation, as well as to identify veterans with a history of VTE events who have completed a sufficient treatment duration.

Methods

Anticoagulation stewardship efforts were implemented in 2 cohorts of patients: those with Afib who may be indicated to initiate anticoagulation, and those with a history of VTE events who may be indicated to consider anticoagulation discontinuation. Patient records were reviewed using a standardized note template, and recommendations to either initiate or discontinue anticoagulation therapy were documented. The VAPHCS Research Service reviewed this study and determined that it was not research and was exempt from institutional review board review.

Atrial Fibrillation Cohort

A population health dashboard created by the Stroke Prevention in Atrial Fibrillation/Flutter Targeting the uNTreated: a focus on health care disparities (SPAFF-TNT-D) national VA study team was used to identify veterans at VAPHCS with a diagnosis of Afib without an active VA prescription for an anticoagulant. The dashboard filtered and produced data points from the medical record that correlated to the components of the CHA₂DS₂-VASc score. All veterans identified by the dashboard with scores of 7 or 8 were included. No patients had a score of 9. Comprehensive chart reviews of available VA and non–VA-provided care records were conducted by the investigators, and a standardized note template designed by the SPAFF-TNT-D team (eAppendix 1) was used to document findings within the electronic health record (EHR). If anticoagulation was deemed to be indicated, the assigned primary care practitioner (PCP) as listed in the EHR was alerted to the note by the investigators for further evaluation and consideration of prescribing anticoagulation.

Venous Thromboembolism Cohort

VAPHCS pharmacy informatics pulled data that included veterans with documented VTE and an active VA anticoagulant prescription between November 2022 and November 2023. Veterans were reviewed in chronological order based on when the anticoagulant prescription was written. All veterans were included until an equal number of charts were reviewed in both the Afib and VTE cohorts. Comprehensive chart review of available VA- and non–VA-provided care records was conducted by the investigators, and a standardized note template as designed by the investigators (eAppendix 2) was used to document findings within the EHR. If the duration of anticoagulation therapy was deemed sufficient, the assigned anticoagulation clinical pharmacist practitioner (CPP) was alerted to the note by the investigators for further evaluation and consideration of discontinuing anticoagulation.

EHR reviews were conducted in October and November 2023 and lasted about 10 to 20 minutes per patient. To evaluate completeness and accuracy of the documented findings within the EHR, both investigators reviewed and cosigned the completed note template and verified the correct PCP was alerted to the recommendation for appropriate continuity of care. Results were reviewed in March 2024.

Outcomes

Atrial fibrillation cohort. The primary outcome was the number of veterans with Afib who were recommended to start anticoagulation therapy. Additional outcomes evaluated included the number of interventions completed, action taken by PCPs in response to the provided recommendation, and reasons provided by the investigators for not recommending initiation of anticoagulation therapy in specific veteran cases.

Venous thromboembolism cohort. The primary outcome was the number of veterans with a history of VTE events recommended to discontinue anticoagulation therapy. Additional outcomes included number of interventions completed, action taken by the anticoagulation CPP in response to the provided recommendation, and reasons provided by the investigators for not recommending discontinuation of anticoagulation therapy in specific veteran cases.

Analysis

Sample size was determined by the inclusion criteria and was not designed to attain statistical power. Data embedded in the Afib cohort standardized note template, also known as health factors, were later used for data analysis. Recommendations in the VTE cohort were manually tracked and recorded by the investigators. Results for this study were analyzed using descriptive statistics.

Results

A total of 114 veterans were reviewed and included in this study: 57 in each cohort. Seven recommendations were made regarding anticoagulation initiation for patients with Afib and 7 were made for anticoagulation discontinuation for patients with VTE (Table 1).

In the Afib cohort, 1 veteran was successfully initiated on anticoagulation therapy and 1 veteran was deemed appropriate for initiation of anticoagulation but was not reachable. Of the 5 recommendations with no action taken, 4 PCPs acknowledged the alert with no further documentation, and 1 PCP deferred the decision to cardiology with no further documentation. In the VTE cohort, 3 veterans successfully discontinued anticoagulation therapy and 2 veterans were further evaluated by the anticoagulation CPP and deemed appropriate to continue therapy based on potential for malignancy. Of the 2 recommendations with no action taken, 1 anticoagulation CPP acknowledged the alert with no further documentation and 1 anticoagulation CPP suggested further evaluation by PCP with no further documentation.

In the Afib cohort, a nonpharmacologic approach was defined as documentation of a LAAO device. An inaccurate diagnosis was defined as an Afib diagnosis being used in a previous visit, although there was no further confirmation of diagnosis via chart review. Veterans classified as already being on anticoagulation had documentation of non–VA-written anticoagulant prescriptions or receiving a supply of anticoagulants from a facility such as a nursing home. Anticoagulation was defined as unfavorable if a documented risk/benefit conversation was found via EHR review. Anticoagulation was defined as not indicated if the Afib was documented as transient, episodic, or historical (Table 2).

In the VTE cohort, no recommendations for discontinuation were made for veterans indicated to continue anticoagulation due to a concurrent Afib diagnosis. Chronic or recurrent events were defined as documentation of multiple VTE events and associated dates in the EHR. Persistent risk factors included malignancy or medications contributing to hypercoagulable states. Thrombophilia was defined as having documentation of a diagnosis in the EHR. An unprovoked event was defined as VTE without any documented transient risk factors (eg, hospitalization, trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel). Anticoagulation had already been discontinued in 1 veteran after the data were collected but before chart review occurred (Table 3).

Discussion

Pharmacy-led indication reviews resulted in appropriate recommendations for anticoagulation use in veterans with Afib and a history of VTE events. Overall, 12.3% of chart reviews in each cohort resulted in a recommendation being made, which was similar to the rate found by Koolian et al.⁵ In that study, 10% of recommendations were related to initiation or interruption of anticoagulation. This recommendation category consisted of several subcategories, including “suggesting therapeutic anticoagulation when none is currently ordered” and “suggesting anticoagulation cessation if no longer indicated,” but specific numerical prevalence was not provided.⁵

Online dashboard use allowed for greater population health management and identification of veterans with Afib who were not on active anticoagulation, providing opportunities to prevent stroke-related complications. Wang et al completed a similarly designed study that included a population health tool to identify patients with Afib who were not on anticoagulation and implemented pharmacist-led chart review and facilitation of recommendations to the responsible clinician. This study reviewed 1727 patients and recommended initiation of anticoagulation therapy for 75 (4.3%).⁶ The current study had a higher percentage of patients with recommendations for changes despite its smaller size.

Evaluating the duration of therapy for anticoagulation in veterans with a history of VTE events provided an opportunity to reduce unnecessary exposure to anticoagulation and minimize bleeding risks. Using a chart review process and standardized note template enabled the documentation of pertinent information that could be readily reviewed by the PCP. This process is a step toward ensuring VAPHCS PCPs provide guideline-recommended care and actively prevent stroke and bleeding complications. Adoption of this process into the current VAPHCS Anticoagulation Clinic workflow for review of veterans with either Afib or VTE could lead to more EHRs being reviewed and recommendations made, ultimately improving patient outcomes. 

Therapeutic interventions based on the recommendations were completed for 1 of 7 veterans (14%) and 3 of 7 veterans (43%) in the Afib and VTE cohorts, respectively. The prevalence of completed interventions in this anticoagulation stewardship study was higher than those in Wang et al, who found only 9% of their recommendations resulted in PCPs considering action related to anticoagulation, and only 4% were successfully initiated.⁶

In the Afib cohort, veterans identified by the dashboard with a CHA₂DS₂-VASc of 7 or 8 were prioritized for review. Reviewing these veterans ensured that patients with the highest stroke risk were sufficiently evaluated and started on anticoagulation as needed to reduce stroke-related complications. In contrast, because these veterans had higher CHA₂DS₂-VASc scores, they may have already been evaluated for anticoagulation in the past and had a documented rationale for not being placed on anticoagulation (LAAO device placement was the most common rationale). Focusing on veterans with a lower CHA₂DS₂-VASc score such as 1 for men or 2 for women could potentially include more opportunities for recommendations. Although stroke risk may be lower in this population compared with those with higher CHA₂DS₂-VASc scores, guideline-recommended anticoagulation use may be missed for these patients. 

In the VTE cohort, veterans with an anticoagulant prescription written 12 months before data collection were prioritized for review. Reviewing these veterans ensured that anticoagulation therapy met guideline recommendations of at least 3 months, with potential for extended duration upon further evaluation by a provider at that time. Based on collected results, most veterans were already reevaluated and had documented reasons why anticoagulation was still indicated; concurrent Afib was most common followed by chronic or recurrent VTE. Reviewing veterans with more recent prescriptions just over the recommended 3-month duration could potentially include more opportunities for recommendations to be made. It is more likely that by 3 months another PCP had not already weighed in on the duration of therapy, and the anticoagulation CPP could ensure a thorough review is conducted with guideline-based recommendations.

Most published literature on anticoagulation stewardship efforts is focused on inpatient management and policy changes, or concentrate on attributes of therapy such as appropriate dosing and drug interactions. This study highlighted that gaps in care related to anticoagulation use and discontinuation are present in the VAPHCS population and can be appropriately addressed via pharmacist-led indication reviews. Future studies designed to focus on initiating anticoagulation where appropriate, and discontinuing where a sufficient treatment period has been completed, are warranted to minimize this gap in care and allow health systems to work toward process changes to ensure safe and optimized care is provided for the patients they serve.

Limitations

In the Afib cohort, 5 of 7 recommendations (71%) had no further action taken by the PCP, which may represent a barrier to care. In contrast, 2 of 7 recommendations (29%) had no further action in the VTE cohort. It is possible that the difference can be attributed to the anticoagulation CPP receiving VTE alerts and PCPs receiving Afib alerts. The anticoagulation CPP was familiar with this QI study and may have better understood the purpose of the chart review and the need to provide a timely response. PCPs may have been less likely to take action because they were unfamiliar with the anticoagulation stewardship initiative and standardized note template or overwhelmed by too many EHR alerts.

The lack of PCP response to a virtual alert or message also was observed by Wang et al, whereas Koolian et al reported higher intervention completion rates, with verbal recommendations being made to the responsible clinicians. To further ensure these pertinent recommendations for anticoagulation initiation in veterans with Afib are properly reviewed and evaluated, future research could include intentional follow-up with the PCP regarding the alert, PCP-specific education about the anticoagulation stewardship initiative and the role of the standardized note template, and collaboration with PCPs to identify alternative ways to relay recommendations in a way that would ensure the completion of appropriate and timely review.

Conclusions

This study identified gaps in care related to anticoagulation needs in the VAPHCS veteran population. Utilizing a standardized indication review process allows pharmacists to evaluate anticoagulant use for both appropriate indication and duration of therapy. Providing recommendations via chart review notes and alerting respective PCPs and CPPs results in veterans receiving safe and optimized care regarding their anticoagulation needs.

Due to the underlying mechanism of atrial fibrillation (Afib), clots can form within the left atrial appendage. Clots that become dislodged may lead to ischemic stroke and possibly death. The 2023 guidelines for atrial fibrillation from the American College of Cardiology and American Heart Association recommend anticoagulation therapy for patients with an Afib diagnosis and a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke/vascular disease, age 65 to 74 years, and female sex) score pertinent for ≥ 1 non–sex-related factor (score ≥ 2 for women; ≥ 1 for men) to prevent stroke-related complications. The CHA₂DS₂-VASc score is a 9-point scoring tool based on comorbidities and conditions that increase risk of stroke in patients with Afib. Each value correlates to an annualized stroke risk percentage that increases as the score increases.

In clinical practice, patients meeting these thresholds are indicated for anticoagulation and are considered for indefinite use unless ≥ 1 of the following conditions are present: bleeding risk outweighs the stroke prevention benefit, Afib is episodic (< 48 hours) or a nonpharmacologic intervention, such as a left atrial appendage occlusion (LAAO) device is present.¹

In patients with a diagnosed venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, anticoagulation is used to treat the current thrombosis and prevent embolization that can ultimately lead to death. The 2021 guideline for VTE from the American College of Chest Physicians identifies certain risk factors that increase risk for VTE and categorizes them as transient or persistent. Transient risk factors include hospitalization > 3 days, major trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel > 8 hours. Persistent risk factors include malignancy, thrombophilia, and certain medications.

The guideline recommends therapy durations based on event frequency, the presence and classification of provoking risk factors, and bleeding risk. As the risk of recurrent thrombosis and other potential complications is greatest in the first 3 to 6 months after a diagnosed event, at least 3 months anticoagulation therapy is recommended following VTE diagnosis. At the 3-month mark, all regimens are suggested to be re-evaluated and considered for extended treatment duration if the event was unprovoked, recurrent, secondary to a persistent risk factor, or low bleed risk.²Anticoagulation is an important guideline-recommended pharmacologic intervention for various disease states, although its use is not without risks. The Institute for Safe Medication Practices has classified oral anticoagulants as high-alert medications. This designation was made because anticoagulant medications have the potential to cause harm when used or omitted in error and lead to life-threatening bleed or thrombotic complications.³Anticoagulation stewardship ensures that anticoagulation therapy is appropriately initiated, maintained, and discontinued when indicated. Because of the potential for harm, anticoagulation stewardship is an important part of Afib and VTE management. Pharmacists can help verify and evaluate anticoagulation therapies. Research suggests that pharmacist-led anticoagulation stewardship efforts may play a role in ensuring safer patient outcomes.⁴The purpose of this quality improvement (QI) study was to implement pharmacist-led anticoagulation stewardship practices at Veterans Affairs Phoenix Health Care System (VAPHCS) to identify veterans with Afib not currently on anticoagulation, as well as to identify veterans with a history of VTE events who have completed a sufficient treatment duration.

Methods

Anticoagulation stewardship efforts were implemented in 2 cohorts of patients: those with Afib who may be indicated to initiate anticoagulation, and those with a history of VTE events who may be indicated to consider anticoagulation discontinuation. Patient records were reviewed using a standardized note template, and recommendations to either initiate or discontinue anticoagulation therapy were documented. The VAPHCS Research Service reviewed this study and determined that it was not research and was exempt from institutional review board review.

Atrial Fibrillation Cohort

A population health dashboard created by the Stroke Prevention in Atrial Fibrillation/Flutter Targeting the uNTreated: a focus on health care disparities (SPAFF-TNT-D) national VA study team was used to identify veterans at VAPHCS with a diagnosis of Afib without an active VA prescription for an anticoagulant. The dashboard filtered and produced data points from the medical record that correlated to the components of the CHA₂DS₂-VASc score. All veterans identified by the dashboard with scores of 7 or 8 were included. No patients had a score of 9. Comprehensive chart reviews of available VA and non–VA-provided care records were conducted by the investigators, and a standardized note template designed by the SPAFF-TNT-D team (eAppendix 1) was used to document findings within the electronic health record (EHR). If anticoagulation was deemed to be indicated, the assigned primary care practitioner (PCP) as listed in the EHR was alerted to the note by the investigators for further evaluation and consideration of prescribing anticoagulation.

Venous Thromboembolism Cohort

VAPHCS pharmacy informatics pulled data that included veterans with documented VTE and an active VA anticoagulant prescription between November 2022 and November 2023. Veterans were reviewed in chronological order based on when the anticoagulant prescription was written. All veterans were included until an equal number of charts were reviewed in both the Afib and VTE cohorts. Comprehensive chart review of available VA- and non–VA-provided care records was conducted by the investigators, and a standardized note template as designed by the investigators (eAppendix 2) was used to document findings within the EHR. If the duration of anticoagulation therapy was deemed sufficient, the assigned anticoagulation clinical pharmacist practitioner (CPP) was alerted to the note by the investigators for further evaluation and consideration of discontinuing anticoagulation.

EHR reviews were conducted in October and November 2023 and lasted about 10 to 20 minutes per patient. To evaluate completeness and accuracy of the documented findings within the EHR, both investigators reviewed and cosigned the completed note template and verified the correct PCP was alerted to the recommendation for appropriate continuity of care. Results were reviewed in March 2024.

Outcomes

Atrial fibrillation cohort. The primary outcome was the number of veterans with Afib who were recommended to start anticoagulation therapy. Additional outcomes evaluated included the number of interventions completed, action taken by PCPs in response to the provided recommendation, and reasons provided by the investigators for not recommending initiation of anticoagulation therapy in specific veteran cases.

Venous thromboembolism cohort. The primary outcome was the number of veterans with a history of VTE events recommended to discontinue anticoagulation therapy. Additional outcomes included number of interventions completed, action taken by the anticoagulation CPP in response to the provided recommendation, and reasons provided by the investigators for not recommending discontinuation of anticoagulation therapy in specific veteran cases.

Analysis

Sample size was determined by the inclusion criteria and was not designed to attain statistical power. Data embedded in the Afib cohort standardized note template, also known as health factors, were later used for data analysis. Recommendations in the VTE cohort were manually tracked and recorded by the investigators. Results for this study were analyzed using descriptive statistics.

Results

A total of 114 veterans were reviewed and included in this study: 57 in each cohort. Seven recommendations were made regarding anticoagulation initiation for patients with Afib and 7 were made for anticoagulation discontinuation for patients with VTE (Table 1).

In the Afib cohort, 1 veteran was successfully initiated on anticoagulation therapy and 1 veteran was deemed appropriate for initiation of anticoagulation but was not reachable. Of the 5 recommendations with no action taken, 4 PCPs acknowledged the alert with no further documentation, and 1 PCP deferred the decision to cardiology with no further documentation. In the VTE cohort, 3 veterans successfully discontinued anticoagulation therapy and 2 veterans were further evaluated by the anticoagulation CPP and deemed appropriate to continue therapy based on potential for malignancy. Of the 2 recommendations with no action taken, 1 anticoagulation CPP acknowledged the alert with no further documentation and 1 anticoagulation CPP suggested further evaluation by PCP with no further documentation.

In the Afib cohort, a nonpharmacologic approach was defined as documentation of a LAAO device. An inaccurate diagnosis was defined as an Afib diagnosis being used in a previous visit, although there was no further confirmation of diagnosis via chart review. Veterans classified as already being on anticoagulation had documentation of non–VA-written anticoagulant prescriptions or receiving a supply of anticoagulants from a facility such as a nursing home. Anticoagulation was defined as unfavorable if a documented risk/benefit conversation was found via EHR review. Anticoagulation was defined as not indicated if the Afib was documented as transient, episodic, or historical (Table 2).

In the VTE cohort, no recommendations for discontinuation were made for veterans indicated to continue anticoagulation due to a concurrent Afib diagnosis. Chronic or recurrent events were defined as documentation of multiple VTE events and associated dates in the EHR. Persistent risk factors included malignancy or medications contributing to hypercoagulable states. Thrombophilia was defined as having documentation of a diagnosis in the EHR. An unprovoked event was defined as VTE without any documented transient risk factors (eg, hospitalization, trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel). Anticoagulation had already been discontinued in 1 veteran after the data were collected but before chart review occurred (Table 3).

Discussion

Pharmacy-led indication reviews resulted in appropriate recommendations for anticoagulation use in veterans with Afib and a history of VTE events. Overall, 12.3% of chart reviews in each cohort resulted in a recommendation being made, which was similar to the rate found by Koolian et al.⁵ In that study, 10% of recommendations were related to initiation or interruption of anticoagulation. This recommendation category consisted of several subcategories, including “suggesting therapeutic anticoagulation when none is currently ordered” and “suggesting anticoagulation cessation if no longer indicated,” but specific numerical prevalence was not provided.⁵

Online dashboard use allowed for greater population health management and identification of veterans with Afib who were not on active anticoagulation, providing opportunities to prevent stroke-related complications. Wang et al completed a similarly designed study that included a population health tool to identify patients with Afib who were not on anticoagulation and implemented pharmacist-led chart review and facilitation of recommendations to the responsible clinician. This study reviewed 1727 patients and recommended initiation of anticoagulation therapy for 75 (4.3%).⁶ The current study had a higher percentage of patients with recommendations for changes despite its smaller size.

Evaluating the duration of therapy for anticoagulation in veterans with a history of VTE events provided an opportunity to reduce unnecessary exposure to anticoagulation and minimize bleeding risks. Using a chart review process and standardized note template enabled the documentation of pertinent information that could be readily reviewed by the PCP. This process is a step toward ensuring VAPHCS PCPs provide guideline-recommended care and actively prevent stroke and bleeding complications. Adoption of this process into the current VAPHCS Anticoagulation Clinic workflow for review of veterans with either Afib or VTE could lead to more EHRs being reviewed and recommendations made, ultimately improving patient outcomes. 

Therapeutic interventions based on the recommendations were completed for 1 of 7 veterans (14%) and 3 of 7 veterans (43%) in the Afib and VTE cohorts, respectively. The prevalence of completed interventions in this anticoagulation stewardship study was higher than those in Wang et al, who found only 9% of their recommendations resulted in PCPs considering action related to anticoagulation, and only 4% were successfully initiated.⁶

In the Afib cohort, veterans identified by the dashboard with a CHA₂DS₂-VASc of 7 or 8 were prioritized for review. Reviewing these veterans ensured that patients with the highest stroke risk were sufficiently evaluated and started on anticoagulation as needed to reduce stroke-related complications. In contrast, because these veterans had higher CHA₂DS₂-VASc scores, they may have already been evaluated for anticoagulation in the past and had a documented rationale for not being placed on anticoagulation (LAAO device placement was the most common rationale). Focusing on veterans with a lower CHA₂DS₂-VASc score such as 1 for men or 2 for women could potentially include more opportunities for recommendations. Although stroke risk may be lower in this population compared with those with higher CHA₂DS₂-VASc scores, guideline-recommended anticoagulation use may be missed for these patients. 

In the VTE cohort, veterans with an anticoagulant prescription written 12 months before data collection were prioritized for review. Reviewing these veterans ensured that anticoagulation therapy met guideline recommendations of at least 3 months, with potential for extended duration upon further evaluation by a provider at that time. Based on collected results, most veterans were already reevaluated and had documented reasons why anticoagulation was still indicated; concurrent Afib was most common followed by chronic or recurrent VTE. Reviewing veterans with more recent prescriptions just over the recommended 3-month duration could potentially include more opportunities for recommendations to be made. It is more likely that by 3 months another PCP had not already weighed in on the duration of therapy, and the anticoagulation CPP could ensure a thorough review is conducted with guideline-based recommendations.

Most published literature on anticoagulation stewardship efforts is focused on inpatient management and policy changes, or concentrate on attributes of therapy such as appropriate dosing and drug interactions. This study highlighted that gaps in care related to anticoagulation use and discontinuation are present in the VAPHCS population and can be appropriately addressed via pharmacist-led indication reviews. Future studies designed to focus on initiating anticoagulation where appropriate, and discontinuing where a sufficient treatment period has been completed, are warranted to minimize this gap in care and allow health systems to work toward process changes to ensure safe and optimized care is provided for the patients they serve.

Limitations

In the Afib cohort, 5 of 7 recommendations (71%) had no further action taken by the PCP, which may represent a barrier to care. In contrast, 2 of 7 recommendations (29%) had no further action in the VTE cohort. It is possible that the difference can be attributed to the anticoagulation CPP receiving VTE alerts and PCPs receiving Afib alerts. The anticoagulation CPP was familiar with this QI study and may have better understood the purpose of the chart review and the need to provide a timely response. PCPs may have been less likely to take action because they were unfamiliar with the anticoagulation stewardship initiative and standardized note template or overwhelmed by too many EHR alerts.

The lack of PCP response to a virtual alert or message also was observed by Wang et al, whereas Koolian et al reported higher intervention completion rates, with verbal recommendations being made to the responsible clinicians. To further ensure these pertinent recommendations for anticoagulation initiation in veterans with Afib are properly reviewed and evaluated, future research could include intentional follow-up with the PCP regarding the alert, PCP-specific education about the anticoagulation stewardship initiative and the role of the standardized note template, and collaboration with PCPs to identify alternative ways to relay recommendations in a way that would ensure the completion of appropriate and timely review.

Conclusions

This study identified gaps in care related to anticoagulation needs in the VAPHCS veteran population. Utilizing a standardized indication review process allows pharmacists to evaluate anticoagulant use for both appropriate indication and duration of therapy. Providing recommendations via chart review notes and alerting respective PCPs and CPPs results in veterans receiving safe and optimized care regarding their anticoagulation needs.

Due to the underlying mechanism of atrial fibrillation (Afib), clots can form within the left atrial appendage. Clots that become dislodged may lead to ischemic stroke and possibly death. The 2023 guidelines for atrial fibrillation from the American College of Cardiology and American Heart Association recommend anticoagulation therapy for patients with an Afib diagnosis and a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke/vascular disease, age 65 to 74 years, and female sex) score pertinent for ≥ 1 non–sex-related factor (score ≥ 2 for women; ≥ 1 for men) to prevent stroke-related complications. The CHA₂DS₂-VASc score is a 9-point scoring tool based on comorbidities and conditions that increase risk of stroke in patients with Afib. Each value correlates to an annualized stroke risk percentage that increases as the score increases.

In clinical practice, patients meeting these thresholds are indicated for anticoagulation and are considered for indefinite use unless ≥ 1 of the following conditions are present: bleeding risk outweighs the stroke prevention benefit, Afib is episodic (< 48 hours) or a nonpharmacologic intervention, such as a left atrial appendage occlusion (LAAO) device is present.¹

In patients with a diagnosed venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, anticoagulation is used to treat the current thrombosis and prevent embolization that can ultimately lead to death. The 2021 guideline for VTE from the American College of Chest Physicians identifies certain risk factors that increase risk for VTE and categorizes them as transient or persistent. Transient risk factors include hospitalization > 3 days, major trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel > 8 hours. Persistent risk factors include malignancy, thrombophilia, and certain medications.

The guideline recommends therapy durations based on event frequency, the presence and classification of provoking risk factors, and bleeding risk. As the risk of recurrent thrombosis and other potential complications is greatest in the first 3 to 6 months after a diagnosed event, at least 3 months anticoagulation therapy is recommended following VTE diagnosis. At the 3-month mark, all regimens are suggested to be re-evaluated and considered for extended treatment duration if the event was unprovoked, recurrent, secondary to a persistent risk factor, or low bleed risk.²Anticoagulation is an important guideline-recommended pharmacologic intervention for various disease states, although its use is not without risks. The Institute for Safe Medication Practices has classified oral anticoagulants as high-alert medications. This designation was made because anticoagulant medications have the potential to cause harm when used or omitted in error and lead to life-threatening bleed or thrombotic complications.³Anticoagulation stewardship ensures that anticoagulation therapy is appropriately initiated, maintained, and discontinued when indicated. Because of the potential for harm, anticoagulation stewardship is an important part of Afib and VTE management. Pharmacists can help verify and evaluate anticoagulation therapies. Research suggests that pharmacist-led anticoagulation stewardship efforts may play a role in ensuring safer patient outcomes.⁴The purpose of this quality improvement (QI) study was to implement pharmacist-led anticoagulation stewardship practices at Veterans Affairs Phoenix Health Care System (VAPHCS) to identify veterans with Afib not currently on anticoagulation, as well as to identify veterans with a history of VTE events who have completed a sufficient treatment duration.

Methods

Anticoagulation stewardship efforts were implemented in 2 cohorts of patients: those with Afib who may be indicated to initiate anticoagulation, and those with a history of VTE events who may be indicated to consider anticoagulation discontinuation. Patient records were reviewed using a standardized note template, and recommendations to either initiate or discontinue anticoagulation therapy were documented. The VAPHCS Research Service reviewed this study and determined that it was not research and was exempt from institutional review board review.

Atrial Fibrillation Cohort

A population health dashboard created by the Stroke Prevention in Atrial Fibrillation/Flutter Targeting the uNTreated: a focus on health care disparities (SPAFF-TNT-D) national VA study team was used to identify veterans at VAPHCS with a diagnosis of Afib without an active VA prescription for an anticoagulant. The dashboard filtered and produced data points from the medical record that correlated to the components of the CHA₂DS₂-VASc score. All veterans identified by the dashboard with scores of 7 or 8 were included. No patients had a score of 9. Comprehensive chart reviews of available VA and non–VA-provided care records were conducted by the investigators, and a standardized note template designed by the SPAFF-TNT-D team (eAppendix 1) was used to document findings within the electronic health record (EHR). If anticoagulation was deemed to be indicated, the assigned primary care practitioner (PCP) as listed in the EHR was alerted to the note by the investigators for further evaluation and consideration of prescribing anticoagulation.

Venous Thromboembolism Cohort

VAPHCS pharmacy informatics pulled data that included veterans with documented VTE and an active VA anticoagulant prescription between November 2022 and November 2023. Veterans were reviewed in chronological order based on when the anticoagulant prescription was written. All veterans were included until an equal number of charts were reviewed in both the Afib and VTE cohorts. Comprehensive chart review of available VA- and non–VA-provided care records was conducted by the investigators, and a standardized note template as designed by the investigators (eAppendix 2) was used to document findings within the EHR. If the duration of anticoagulation therapy was deemed sufficient, the assigned anticoagulation clinical pharmacist practitioner (CPP) was alerted to the note by the investigators for further evaluation and consideration of discontinuing anticoagulation.

EHR reviews were conducted in October and November 2023 and lasted about 10 to 20 minutes per patient. To evaluate completeness and accuracy of the documented findings within the EHR, both investigators reviewed and cosigned the completed note template and verified the correct PCP was alerted to the recommendation for appropriate continuity of care. Results were reviewed in March 2024.

Outcomes

Atrial fibrillation cohort. The primary outcome was the number of veterans with Afib who were recommended to start anticoagulation therapy. Additional outcomes evaluated included the number of interventions completed, action taken by PCPs in response to the provided recommendation, and reasons provided by the investigators for not recommending initiation of anticoagulation therapy in specific veteran cases.

Venous thromboembolism cohort. The primary outcome was the number of veterans with a history of VTE events recommended to discontinue anticoagulation therapy. Additional outcomes included number of interventions completed, action taken by the anticoagulation CPP in response to the provided recommendation, and reasons provided by the investigators for not recommending discontinuation of anticoagulation therapy in specific veteran cases.

Analysis

Sample size was determined by the inclusion criteria and was not designed to attain statistical power. Data embedded in the Afib cohort standardized note template, also known as health factors, were later used for data analysis. Recommendations in the VTE cohort were manually tracked and recorded by the investigators. Results for this study were analyzed using descriptive statistics.

Results

A total of 114 veterans were reviewed and included in this study: 57 in each cohort. Seven recommendations were made regarding anticoagulation initiation for patients with Afib and 7 were made for anticoagulation discontinuation for patients with VTE (Table 1).

In the Afib cohort, 1 veteran was successfully initiated on anticoagulation therapy and 1 veteran was deemed appropriate for initiation of anticoagulation but was not reachable. Of the 5 recommendations with no action taken, 4 PCPs acknowledged the alert with no further documentation, and 1 PCP deferred the decision to cardiology with no further documentation. In the VTE cohort, 3 veterans successfully discontinued anticoagulation therapy and 2 veterans were further evaluated by the anticoagulation CPP and deemed appropriate to continue therapy based on potential for malignancy. Of the 2 recommendations with no action taken, 1 anticoagulation CPP acknowledged the alert with no further documentation and 1 anticoagulation CPP suggested further evaluation by PCP with no further documentation.

In the Afib cohort, a nonpharmacologic approach was defined as documentation of a LAAO device. An inaccurate diagnosis was defined as an Afib diagnosis being used in a previous visit, although there was no further confirmation of diagnosis via chart review. Veterans classified as already being on anticoagulation had documentation of non–VA-written anticoagulant prescriptions or receiving a supply of anticoagulants from a facility such as a nursing home. Anticoagulation was defined as unfavorable if a documented risk/benefit conversation was found via EHR review. Anticoagulation was defined as not indicated if the Afib was documented as transient, episodic, or historical (Table 2).

In the VTE cohort, no recommendations for discontinuation were made for veterans indicated to continue anticoagulation due to a concurrent Afib diagnosis. Chronic or recurrent events were defined as documentation of multiple VTE events and associated dates in the EHR. Persistent risk factors included malignancy or medications contributing to hypercoagulable states. Thrombophilia was defined as having documentation of a diagnosis in the EHR. An unprovoked event was defined as VTE without any documented transient risk factors (eg, hospitalization, trauma, surgery, cast immobilization, hormone therapy, pregnancy, or prolonged travel). Anticoagulation had already been discontinued in 1 veteran after the data were collected but before chart review occurred (Table 3).

Discussion

Pharmacy-led indication reviews resulted in appropriate recommendations for anticoagulation use in veterans with Afib and a history of VTE events. Overall, 12.3% of chart reviews in each cohort resulted in a recommendation being made, which was similar to the rate found by Koolian et al.⁵ In that study, 10% of recommendations were related to initiation or interruption of anticoagulation. This recommendation category consisted of several subcategories, including “suggesting therapeutic anticoagulation when none is currently ordered” and “suggesting anticoagulation cessation if no longer indicated,” but specific numerical prevalence was not provided.⁵

Online dashboard use allowed for greater population health management and identification of veterans with Afib who were not on active anticoagulation, providing opportunities to prevent stroke-related complications. Wang et al completed a similarly designed study that included a population health tool to identify patients with Afib who were not on anticoagulation and implemented pharmacist-led chart review and facilitation of recommendations to the responsible clinician. This study reviewed 1727 patients and recommended initiation of anticoagulation therapy for 75 (4.3%).⁶ The current study had a higher percentage of patients with recommendations for changes despite its smaller size.

Evaluating the duration of therapy for anticoagulation in veterans with a history of VTE events provided an opportunity to reduce unnecessary exposure to anticoagulation and minimize bleeding risks. Using a chart review process and standardized note template enabled the documentation of pertinent information that could be readily reviewed by the PCP. This process is a step toward ensuring VAPHCS PCPs provide guideline-recommended care and actively prevent stroke and bleeding complications. Adoption of this process into the current VAPHCS Anticoagulation Clinic workflow for review of veterans with either Afib or VTE could lead to more EHRs being reviewed and recommendations made, ultimately improving patient outcomes. 

Therapeutic interventions based on the recommendations were completed for 1 of 7 veterans (14%) and 3 of 7 veterans (43%) in the Afib and VTE cohorts, respectively. The prevalence of completed interventions in this anticoagulation stewardship study was higher than those in Wang et al, who found only 9% of their recommendations resulted in PCPs considering action related to anticoagulation, and only 4% were successfully initiated.⁶

In the Afib cohort, veterans identified by the dashboard with a CHA₂DS₂-VASc of 7 or 8 were prioritized for review. Reviewing these veterans ensured that patients with the highest stroke risk were sufficiently evaluated and started on anticoagulation as needed to reduce stroke-related complications. In contrast, because these veterans had higher CHA₂DS₂-VASc scores, they may have already been evaluated for anticoagulation in the past and had a documented rationale for not being placed on anticoagulation (LAAO device placement was the most common rationale). Focusing on veterans with a lower CHA₂DS₂-VASc score such as 1 for men or 2 for women could potentially include more opportunities for recommendations. Although stroke risk may be lower in this population compared with those with higher CHA₂DS₂-VASc scores, guideline-recommended anticoagulation use may be missed for these patients. 

In the VTE cohort, veterans with an anticoagulant prescription written 12 months before data collection were prioritized for review. Reviewing these veterans ensured that anticoagulation therapy met guideline recommendations of at least 3 months, with potential for extended duration upon further evaluation by a provider at that time. Based on collected results, most veterans were already reevaluated and had documented reasons why anticoagulation was still indicated; concurrent Afib was most common followed by chronic or recurrent VTE. Reviewing veterans with more recent prescriptions just over the recommended 3-month duration could potentially include more opportunities for recommendations to be made. It is more likely that by 3 months another PCP had not already weighed in on the duration of therapy, and the anticoagulation CPP could ensure a thorough review is conducted with guideline-based recommendations.

Most published literature on anticoagulation stewardship efforts is focused on inpatient management and policy changes, or concentrate on attributes of therapy such as appropriate dosing and drug interactions. This study highlighted that gaps in care related to anticoagulation use and discontinuation are present in the VAPHCS population and can be appropriately addressed via pharmacist-led indication reviews. Future studies designed to focus on initiating anticoagulation where appropriate, and discontinuing where a sufficient treatment period has been completed, are warranted to minimize this gap in care and allow health systems to work toward process changes to ensure safe and optimized care is provided for the patients they serve.

Limitations

In the Afib cohort, 5 of 7 recommendations (71%) had no further action taken by the PCP, which may represent a barrier to care. In contrast, 2 of 7 recommendations (29%) had no further action in the VTE cohort. It is possible that the difference can be attributed to the anticoagulation CPP receiving VTE alerts and PCPs receiving Afib alerts. The anticoagulation CPP was familiar with this QI study and may have better understood the purpose of the chart review and the need to provide a timely response. PCPs may have been less likely to take action because they were unfamiliar with the anticoagulation stewardship initiative and standardized note template or overwhelmed by too many EHR alerts.

The lack of PCP response to a virtual alert or message also was observed by Wang et al, whereas Koolian et al reported higher intervention completion rates, with verbal recommendations being made to the responsible clinicians. To further ensure these pertinent recommendations for anticoagulation initiation in veterans with Afib are properly reviewed and evaluated, future research could include intentional follow-up with the PCP regarding the alert, PCP-specific education about the anticoagulation stewardship initiative and the role of the standardized note template, and collaboration with PCPs to identify alternative ways to relay recommendations in a way that would ensure the completion of appropriate and timely review.

Conclusions

This study identified gaps in care related to anticoagulation needs in the VAPHCS veteran population. Utilizing a standardized indication review process allows pharmacists to evaluate anticoagulant use for both appropriate indication and duration of therapy. Providing recommendations via chart review notes and alerting respective PCPs and CPPs results in veterans receiving safe and optimized care regarding their anticoagulation needs.