Veterans may not be the only ones suffering heat-related illnesses (HRI) from rising temps around the nation, but the Veterans Affairs Department nonetheless wants to make sure it addresses the increasing number of HRI cases its seeing at its facilities. Recently, the agency published an assessment that shows 18 years’ worth of HRI-related data among Veterans. To get a breakdown of what trends the agency found and what it’s doing to address them, Federal Drive with Tom Temin Executive Producer spoke to Thomas Osborne, the director of VA’s National Center for Collaborative Healthcare Innovation.
Thomas Osborne You know, the VA is a big place. The VA is the largest integrated health care system in United States. And there’s a lot of efforts, people all over the institution working hard to provide the best care possible for our patients, our veterans. One of the things that we did early on was recognize that climate and heat are important and potentially very important for our patients’ health. There were quite a few different publications out before that suggested that older patients and those with multiple comorbidities and other things could be at higher risk for bad outcomes from heat and environmental changes. So we looked to try to better understand what that would mean for our patient population, and we couldn’t find anything that was already written. So our team decided to do our investigation with our own data and resources, and we collaborated with some great people at the CDC and they brought their knowledge and expertise and we utilized our data to understand what was going on. And we recently just published a pretty impactful, probably the largest paper, peer reviewed academic paper on the topic, and a lot of really interesting insights that are designed to be used to help inform and to use data and make data informed decisions about how to best mitigate the risks.
Eric White Yep. Can you tell me about just a few of those top level insights that you all found pertaining to how the heat is affecting the patients of the VA, veterans in particular?
Thomas Osborne So this manuscript, this paper was I think, pretty interesting in a lot of ways. First of all, we looked at 18 years of historical data, so the VA does a really good job at keeping track of our patients’ records and data in our electronic health record. And it’s a really robust resource. And so we looked back 18 years at the trends and we tried to understand the risks and the variables which were important and some of the things that we sort of expected and we were thinking might be the case, but we were able to quantify it and other things that we found were simply quite surprising. And so some of the things that we expected was that, you know, some people would be more at risk for heat related illness than others. And in particular, we found that those who have multiple comorbidities in particular and some demographic groups were at more risk for heat related illness than others. Some of the things that we were kind of surprised about was that the trends across the country, because we looked at areas of the country that had different proportions of heat related illnesses and the trends across the country were a little surprising. One is that the trends over the 18 years that we looked at were steadily going up just about every state, everywhere some states, the trends showed that the heat related illnesses were increasing more than others. And we kind of expected that. You know, when we first looked at it, the trends would show that people who are living more in more southern states were going to have more cases of heat related illnesses than people in northern states because of just the climatic zones. But we found that that was not necessarily true and that surprised us. And what we think is going on is some traditionally warmer states are already sort of addressing the issue with, you know, education programs and outreach programs and mitigation plans where maybe some of the states in the northern climates are perhaps less used to or less expecting climate to be affecting people in the way that it’s been in the last decade or so. And the increase over time, I think, is possibly getting people off guard because, you know, like if you live, you know, maybe in Maine or a different northern state, you may not have an air conditioner, you know, but maybe if you lived down in Florida, you do have an air conditioner. So there’s different things based on where you typically, you know, built a house back in the day with insulation for different things that you may be ready for or maybe not ready for. And so that was a big surprise. The other surprise that I was not expecting, and I don’t think we were expecting either, is when we look at our homeless population, we were expecting that they would be more impacted just because of the increased exposure that you would have if you don’t have a roof. And so what we did is we looked at. That, and it was increasing steadily over time. But in the last half of our assessment, it actually decreased. So if you look at the graph, it almost looks like a peak where it was steadily going up. And then over the last half of the assessment period, it went down. And what it seems to be going on is right around that time the VA was expanding and developing and deploying a number of homeless outreach and mitigation programs. And those two things coincided pretty closely. So in all of this, there’s some hope that, you know, there are things that we can do to prevent the consequences of extreme heat in the environment and in particular, how it relates to health.
Eric White Getting down on the ground of actually treating patients. What is it that more facilities are seeing? Is it just, you know, the basics of heat exhaustion and dehydration and obviously irritating any current conditions they already have? Are there any challenges to treating other patients compared to ones who might need a little bit more care, like the more vulnerable homeless population?
Thomas Osborne Yeah, that’s a really great and pretty, pretty deep question on a lot of levels. There’s a lot to unpack there, so for sure there are so many different variables that we looked at and what we really were focused in on this particular assessment, we’ve got others in the works is the admissions why people are coming into the hospital when in particular what are the ICD ten codes and ICD nine codes, which is sort of the classification code for different diseases? What are those codes being marked as when someone comes into the hospital? And what we did see is these codes that are specifically for heat, like heat exhaustion, like you said, those have been going up over time. Now, that’s kind of an important thing because just looking at that data, you’re going to have some missing information because if you come into the hospital and you have a heart attack or a stroke or something like that, that is likely what you’re going to be coded for. But that heart attack or stroke could have been exacerbated by heat. In that case, you may not have coded somebody for heat related illness and heart attack. And sometimes you just, you know, would code them for a heart attack. So there’s likely missing data. You know, a lot of research has suggested and our data also suggest that the incidence is much more than what we actually counted for. We took a conservative approach and just looking at the cases or the times, people came to the hospital with a specific diagnostic code that said heat related illness. But there’s probably much more because people come into the hospital for a variety of reasons, and sometimes they have other illnesses that are exacerbated because of the heat.
Eric White Yeah, with so many of those vulnerabilities that you have to take into consideration, you know, top level from a policymaking standpoint, what can you use this data for in formulating a way to prepare facilities possibly for more heat related illnesses? Are there, you know, say, hey, you know, there’s a heat wave coming, You know, maybe be ready for more of those, you know, older folks coming in with heart conditions or things of that nature. Is that kind of what the data might be utilized for?
Thomas Osborne That’s a yeah, for sure. That’s a great question. So that’s very much I appreciate that question because that’s very much our intent is to understand the challenge, understand what’s going on objectively, and then with that information, to use that to make data informed decisions about how to mitigate those risks. And in particular, it would also be fantastic, like you suggested, is to have some sort of predictive model where, you know, you know, somebody’s background or, you know, a particular background that someone could fit into. And if the temperature hits a certain threshold that puts that particular person or type of population at risk, then we know that there’s a flag. This is a threshold that we should understand. So then we can reach out to those folks and try to avert a crisis, you know, and some things that you can do. You know, there’s a lot of things you can do. I mean, education can happen any time. But also, you know, there’s cooling centers. A lot of different areas have cooling centers. But if you don’t have a cooling center, then maybe someone can come to the hospital and, you know, just hang out there or maybe, you know, if you can’t make it to the hospital, go to malls and things like that. But overall, the big picture that you really mentioned I think is super important is how are we as a country going to address this? Because, you know, no one is immune from the ill effects of heat, no matter who you are, young or old. And this is not just an issue for the VA, although our patient population tends to be older and has more co-morbidities, so in particular at risk. But, you know, heat related illnesses like you’re suggesting can happen to anybody. And so the insights that we have, the VA can help others better inform what to do. And so I’ve been part of this group, which is the NIHHIS, the National Integrated Heat and Health information system for quite a few years. And that’s where I am right now. I’m in a side conference room because we have this interagency working group working on our strategic our federal Heat strategic plan with 23 different agencies. So I just popped out. And so I apologize if there’s background echo in this side room, but that’s exactly what we’re doing, is what you’re suggesting is to come together as a country with many different agencies, with different perspectives, to try to understand how we can work well together, to be successful, but also get the perspectives of different agencies so we can do this in a holistic way so our country can be as prosperous and healthy as possible.