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  • Breast Cancer Trtmn

     

    General Information About Breast Cancer

    KEY POINTS

    • Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.
    • A family history of breast cancer and other factors increase the risk of breast cancer.
    • Breast cancer is sometimes caused by inherited gene mutations (changes).
    • The use of certain medicines and other factors decrease the risk of breast cancer.
    • Signs of breast cancer include a lump or change in the breast.
    • Tests that examine the breasts are used to detect (find) and diagnose breast cancer.
    • If cancer is found, tests are done to study the cancer cells.
    • Certain factors affect prognosis (chance of recovery) and treatment options.

    Breast cancer is a disease in which malignant (cancer) cells form in the tissues of the breast.

    The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes. Each lobe has many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can make milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.

    Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels carry lymph between lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter substances in lymph and help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.

    The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.

    See the following PDQ summaries for more information about breast cancer:

    A family history of breast cancer and other factors increase the risk of breast cancer.

    Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk to your doctor if you think you may be at risk for breast cancer.

    Risk factors for breast cancer include the following:

    Older age is the main risk factor for most cancers. The chance of getting cancer increases as you get older.

    NCI's Breast Cancer Risk Assessment Tool uses a woman's risk factors to estimate her risk for breast cancer during the next five years and up to age 90. This online tool is meant to be used by a health care provider. For more information on breast cancer risk, call 1-800-4-CANCER.

    Breast cancer is sometimes caused by inherited gene mutations (changes).

    The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary breast cancer makes up about 5% to 10% of all breast cancer. Some mutated genes related to breast cancer are more common in certain ethnic groups.

    Women who have certain gene mutations, such as a BRCA1 or BRCA2 mutation, have an increased risk of breast cancer. These women also have an increased risk of ovarian cancer, and may have an increased risk of other cancers. Men who have a mutated gene related to breast cancer also have an increased risk of breast cancer. For more information, see thePDQ summary on Male Breast Cancer Treatment.

    There are tests that can detect (find) mutated genes. These genetic tests are sometimes done for members of families with a high risk of cancer. See thePDQ summary on Genetics of Breast and Gynecologic Cancers for more information.

    The use of certain medicines and other factors decrease the risk of breast cancer.

    Anything that decreases your chance of getting a disease is called a protective factor.

    Protective factors for breast cancer include the following:

    Signs of breast cancer include a lump or change in the breast.

    These and other signs may be caused by breast cancer or by other conditions. Check with your doctor if you have any of the following:

    • A lump or thickening in or near the breast or in the underarm area.
    • A change in the size or shape of the breast.
    • A dimple or puckering in the skin of the breast.
    • nipple turned inward into the breast.
    • Fluid, other than breast milk, from the nipple, especially if it's bloody.
    • Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of skin around the nipple).
    • Dimples in the breast that look like the skin of an orange, called peau d’orange.

    Tests that examine the breasts are used to detect (find) and diagnose breast cancer.

    Check with your doctor if you notice any changes in your breasts. The following tests and procedures may be used:

    • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
    • Clinical breast exam (CBE): An exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual.
    • Mammogram: An x-ray of the breast.

    Breast Cancer Trtmn 002

    • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
    • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of both breasts. This procedure is also called nuclear magnetic resonance imaging (NMRI).
    • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
    • Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a lump in the breast is found, a biopsy may be done.

    There are four types of biopsy used to check for breast cancer:

    If cancer is found, tests are done to study the cancer cells.

    Decisions about the best treatment are based on the results of these tests. The tests give information about:

    • how quickly the cancer may grow.
    • how likely it is that the cancer will spread through the body.
    • how well certain treatments might work.
    • how likely the cancer is to recur (come back).

    Tests include the following:

    • Estrogen and progesterone receptor test : A test to measure the amount of estrogen and progesterone (hormones) receptors in cancer tissue. If there are more estrogen and progesterone receptors than normal, the cancer is called estrogen and/or progesterone receptor positive. This type of breast cancer may grow more quickly. The test results show whether treatment to block estrogen and progesterone may stop the cancer from growing.
    • Human epidermal growth factor type 2 receptor (HER2/neu) test: A laboratory test to measure how many HER2/neu genes there are and how much HER2/neu protein is made in a sample of tissue. If there are more HER2/neu genes or higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. This type of breast cancer may grow more quickly and is more likely to spread to other parts of the body. The cancer may be treated with drugs that target the HER2/neu protein, such as trastuzumab and pertuzumab.
    • Multigene tests: Tests in which samples of tissue are studied to look at the activity of many genes at the same time. These tests may help predict whether cancer will spread to other parts of the body or recur (come back).

    There are many types of multigene tests. The following multigene tests have been studied in clinical trials:

      • Oncotype DX: This test helps predict whether stage I or stage II breast cancer that is estrogen receptor positive and node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.
      • MammaPrint: This test helps predict whether stage I or stage II breast cancer that is node negative will spread to other parts of the body. If the risk that the cancer will spread is high, chemotherapy may be given to lower the risk.

    Based on these tests, breast cancer is described as one of the following types:

    This information helps the doctor decide which treatments will work best for your cancer.

    Certain factors affect prognosis (chance of recovery) and treatment options.

    The prognosis (chance of recovery) and treatment options depend on the following:

    • The stage of the cancer (the size of the tumor and whether it is in the breast only or has spread to lymph nodes or other places in the body).
    • The type of breast cancer.
    • Estrogen receptor and progesterone receptor levels in the tumor tissue.
    • Human epidermal growth factor type 2 receptor (HER2/neu) levels in the tumor tissue.
    • Whether the tumor tissue is triple negative (cells that do not have estrogen receptors, progesterone receptors, or high levels of HER2/neu).
    • How fast the tumor is growing.
    • How likely the tumor is to recur (come back).
    • A woman’s age, general health, and menopausal status (whether a woman is still having menstrual periods).
    • Whether the cancer has just been diagnosed or has recurred (come back).

    Source

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  • Jim Sherman

     

    COLORADO SPRINGS, Colo. (KKTV) - Hundreds of Veterans in our community who are turning 65 years old will need to find a new doctor. Right now, they go to Evans Army Hospital on Fort Carson. Fort Carson told our 11 Call for Action team they are making changes to make room for an influx of active duty soldiers.

    Jim Sherman, a 64-year-old Veteran, gets his care at Evans Army Hospital. But he got a letter saying when he turns 65, because he is eligible for Medicare and TRICARE, his coverage will change and that he will no longer be able to see his doctor at Evans.

    "I was discharged almost 40 years ago, and since that time, that's where I've received my care," Sherman said. "I'm down there -- not every week, maybe every other week, and definitely every month."

    "To just kick everybody to the curb, is not right," he added.

    We reached out to Fort Carson and they told us about 365 letters were sent out to beneficiaries.

    Evans Army Community Hospital said in a statement: "Our mission atEvansArmyCommunityHospital is to ensure the medical readiness of active-duty Soldiers atFortCarson. Due to the increased assignment of Soldiers toFortCarson, Evans is reaching its capacity to provide quality healthcare to our beneficiaries. Evans is notifying beneficiaries approaching their 65th birthday about changes to their healthcare eligibility within the medical treatment facility. Once beneficiaries turn 65, their coverage becomes TRICARE for Life after they enroll in Medicare Part A & B. TRICARE for Life is a Medicare-wraparound coverage for TRICARE-eligible beneficiaries. We are trying to provide beneficiaries sufficient time to find primary care providers in the local community before they turn 65. TRICARE for Life beneficiaries will continue to receive Emergency Care and other services on a space-available basis atEvansArmyCommunityHospital, such as the Pharmacy, Laboratory and Radiology."

    If patients are over 65 and have been getting care at Evans for more than a year, they can stay at the hospital.

    "I am where I want to be," said Sherman. "That's really the only home that I've ever known for hospital care."

    Jim turns 65 in January. He applied for an exception and is waiting to find out if he can stay at Evans.

    In the next two years, Fort Carson said they expect to see an increase of about 1,000 soldiers and 1,500 family members.

    Source

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  • Scapegoat

     

    "Political pressure" forced the Des Moines Veterans hospital to renege on a deal that allowed a longtime physician to quietly retire amid allegations of incompetence, a newly filed federal lawsuit alleges.

    The lawsuit, filed by primary care physician Dr. Ashok Manglik of Des Moines, accuses the U.S. Department of Veterans Affairs, facing “political” pressure in the immediate aftermath of the 2016 presidential election, of deciding to purge from its ranks all physicians alleged to be incompetent — including him.

    The lawsuit claims the alleged effort was triggered by “relentless nationwide criticism” over allegations that doctors accused of incompetence by some VA hospitals had not been reported to state and national licensing authorities.

    Manglik says that in late 2016 he inquired why his pay increase at the Veterans Affairs Central Iowa Health Care System was less than some of his colleagues'. Manglik pointed out that he had been employed by the VA for 19 years.

    Four days later, he alleges, the hospital informed him he was effectively fired, with his privileges summarily suspended.

    Court records show the hospital informed Manglik of this action in a letter that said his clinical practice had “so significantly failed” to meet generally accepted standards it raised “reasonable concern for the safety of patients.”

    In a hospital “Proficiency Report” on Manglik, the hospital’s chief of staff wrote: ”I have significant concerns about (Manglik’s) clinical competence. … Nearly 100 patients have requested another MD in the last year.”

    Manglik appealed the hospital’s actions and in October 2017 reached a settlement with the hospital, agreeing to leave in exchange for $5,000 and a promise that his departure would be treated as a retirement and his personnel file would be purged of any reference to discipline or termination.

    A lawyer for the VA later assured Manglik’s attorney that in the future, if prospective employers or other individuals were to contact the VA about Manglik, the hospital would say he retired and “that is all they would say and nothing more,” records show.

    After the deal was signed, however, the hospital allegedly informed the Iowa Board of Medicine and the National Practitioner Data Bank that Manglik had resigned while under investigation.

    In his lawsuit, Manglik alleges this was done “solely to meet the desperate national agency’s need to offset the relentless criticism of the agency for failing to report deficiencies.”

    Manglik claims he was “a convenient and timely scapegoat to improve the agency’s statistics as quickly as possible after the election.”

    In a sworn affidavit accompanying the lawsuit, Manglik said that by pursuing a deal that would allow him to retire, he was able to preserve his health insurance and collect retirement income that otherwise wouldn’t have been available.

    “I have temporary employment which is now jeopardized, but my ability to transfer, or to see other opportunities, have been destroyed,” Manglik said.

    The hospital hasn't file a response to the lawsuit.

    Source

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  • 5 Drs Out at Mn

     

    ATLANTA -- In another blow to Marietta-based MiMedx, the Veterans Affairs Medical Center in Minneapolis has parted ways with four podiatrists and a dermatologist over improprieties with the company's bio-pharma products, a VA spokesman confirmed for The Atlanta Journal-Constitution.

    The company is under fire amid accusations of "channel stuffing" by ex-employees -- lobbying friendly doctors and medical staffers to overstock and over-use products, thereby inflating revenue reports and driving up stocks.

    In May, three South Carolina VA workers were indicted on federal health care fraud charges, accused of excessive use of MiMedx products on Veterans after accepting gift cards, meals and other inducements from a company representative. Two of the three workers were also charged with accepting bribes.

    The company has launched an internal investigation, and in June, MiMedx announced that it will revise more than five years of financial statements. In July, prominent Atlanta businessman Parker "Pete" Petit stepped down as the company's CEO and chairman. The company remains under scrutiny from the U.S. Department of Justice, the U.S. Securities and Exchange Commission, the Food and Drug Administration and the Department of Veterans Affairs.

    Details behind the Minneapolis doctors' departures aren't clear. The spokesman, Ralph Heussner, said the VA proposed terminating all five, but each opted to resign or retire. He confirmed that the proposed terminations involved issues with MiMedx products.

    Huessner explained in an email that the doctors "engaged in behavior that is not in line with the norms and values of the department.

    "VA has made clear that it will hold employees accountable when they to fail to live up to the high standards taxpayers expect from us," the email said, "and that's exactly what we're doing in this case."

    Source

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  • Prostate Cancer

     

    Lifework inspired by grandfather’s illness

    While at Northwestern Medical School, Dr. Stacy Loeb learned that her grandfather was diagnosed with prostate cancer. His struggle with the illness inspired her to take on the professional challenge of becoming a clinician and researcher in the field of urology.

    She was committed to finding better ways to treat this very common disease for which treatment options often came with difficult side effects. While treatment is usually less traumatic than it was even ten years ago, Dr. Loeb’s research continually looks for even better ways to manage prostate cancer.

    Loeb is the daughter of a Navy Veteran and granddaughter of a Veteran who served in the Air Force in WW II.

    She is a urologist at VA NY Harbor Healthcare System (Manhattan Campus) and assistant professor in the urology and population health departments at NYU School of Medicine.

    She currently splits her time between seeing patients and research for multiple studies. She says she, “loves the combination,” explaining that it allows her to experience in a “full circle way,” the results of each discussion with a patient in the exam room, leading to new research ideas and then bringing the results back to the clinic to help improve patient care. Her time spent in each of these areas can lend itself, in real-time fashion, to immediate results.

    All in the VA family

    Loeb is proud to be working with VA at the forefront of these studies. Prostate cancer treatment and research are never far from her mind. Her husband, Dr. James Borin, is also a VA New York urologist who directs the robotic urology program for patients pursuing surgical management.

    Funded by research grants from the National Institutes of Health, the New York State Department of Health, and the Prostate Cancer Foundation, Loeb and her team are able to advance the research of prostate

    cancer. They are specifically studying a recent trend of what is known as “active surveillance” or “watchful waiting,” that reduces the rush to treatment and opts out of immediate surgery or radiation. For men with low-risk prostate cancer, this is a safe option that can preserve the quality of life. Personal goals and quality of life vary greatly from patient to patient and treatment options need to be tailored to these preferences.

    Loeb’s research is garnering national attention. Research for which she was a primary investigator was published in the May 15 issue of Journal of the American Medical Association (JAMA). Record numbers of Veterans diagnosed with non-aggressive prostate cancer are heeding the advice of international medical experts and opting out of immediate surgery or radiation to treat their cancer.

    Postponing surgery: watchful waiting

    Instead, according to a study led by Loeb and her colleagues from the Manhattan campus of the VA NY Harbor Healthcare System, NYU School of Medicine, and its Perlmutter Cancer Center, increasing numbers of these men are electing to postpone additional therapy unless their symptoms worsen — a passive practice called watchful waiting — or they are choosing so-called active surveillance.

    This program relies on regular check-ups, including blood tests, physical exams, and the occasional needle sampling of prostate tissue to check for any signs of a tumor getting worse, such as fast growth, before aggressive treatment is considered.

    One of the largest studies of its kind, it involved a review of the medical records of 125,083 former servicemen, mostly over the age of 55, who were newly diagnosed with low-risk prostate cancer between 2005 and 2015.

    Taking this research to the next step, Loeb and her team are developing a complex mathematical model guide to best practices on the type and frequency of testing to be used during active surveillance. Their hope is that this research can expand the use of active surveillance and help more men with favorable risk prostate cancer avoid unnecessary treatment.

    Source

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  • Too Few Docs and Nurses

     

    Bridget Villegas, a medical support specialist, at an operating room in a Veterans Health Administration medical center in Aurora, Colorado. Colorado had one of the nation’s highest rates of staffing vacancies for VHA facilities.

    As the nation prepares to honor its Veterans Nov. 12, many Veterans in rural areas and some cities still face long wait times for health care because there aren’t enough doctors, nurses and support staff to provide it.

    Almost 40,000 of the 335,000 positions in the Veterans Health Administration are vacant, according to the Department of Veterans Affairs, which oversees the VHA. The VHA serves about 9 million Veterans.

    The VHA’s turnover rate is less than half the rate for the health care industry overall.

    However, a Stateline analysis of recently released federal figures shows the VHA has a severe vacancy problem in high-cost urban areas such as Los Angeles and Washington, D.C., and in largely rural states, such as Montana and Colorado.

    Montana and Colorado have the highest state job vacancy rates at more than 20 percent, followed by Utah, Oklahoma and Maryland. At the other end, vacancies in Connecticut, Hawaii, Michigan, Minnesota, New Mexico and Rhode Island are less than 8 percent.

    Veterans Health Administration Struggling to Fill Vacancies

    There are nearly 40,000 job vacancies, mostly medical and dental workers, at Veterans Health Administration health centers around the country. As a percentage of filled jobs, the vacancy rates range from more than 20 percent in Montana and Colorado to 2 percent in Hawaii.

    In some ways, the challenges facing the VHA are the same ones facing the health care workforce as a whole, especially in rural areas like Montana, said Kristin Mattocks, a Montana native and associate professor at the University of Massachusetts Medical School who has studied VHA efforts to improve care for Veterans.

    Nationally, job openings in the health care sector have nearly tripled to 1.1 million since 2010, according to Bureau of Labor Statistics data. Most of the communities with shortages of health care workers are in rural areas, according to the Health Resources and Services Administration. There are also shortages in Honolulu, Hawaii, Los Angeles and Washington, D.C.

    As more doctors and other providers in the VHA and elsewhere have been retiring, there’s more pressure on the remaining doctors to absorb more patients and speed up appointments.

    “Now the pressure is put on physicians, which is probably driving some folks” away, Mattocks said.

    The vacancy rates, detailed in a new report required by legislation Congress approved this year, can cause long wait times for appointments, create waitlists for artificial limbs and lead to unsanitary conditions.

    Most of the nearly 40,000 vacancies are for medical and dental staff such as doctors and nurses. Those professionals are hard to find and keep because VHA’s hiring process is time-consuming and the pay is lower than in the private sector.

    And because there isn’t sufficient support staff, many VHA doctors say they are frustrated by having to do more paperwork and even clean offices, federal audits have shown.

    In Colorado last year, the Denver Post found that the VHA postponed surgeries because it didn’t have enough anesthesiologists. Understaffing led to dirty storage rooms and canceled surgeries for anesthetized patients at the VHA’s flagship hospital in Washington, D.C.

    And Veterans in Connecticut had a hard time getting appointments for counseling because four key jobs were vacant earlier this year. U.S. Sen. Richard Blumenthal, a Democrat from Connecticut, in a September hearing called the vacancy figures “really staggering.”

    Blumenthal added that leaders of the local Veterans of Foreign Wars chapter had complained that care was held up at a Norwich, Connecticut, clinic because the local office lacked a director, a case manager, an outreach coordinator and a counselor.

    At the same hearing, Secretary of Veterans Affairs Robert Wilkie also expressed alarm about the number of vacancies. And he said hiring for mental health centers such as the one in Connecticut is a priority.

    “On its face it is staggering,” Wilkie said. “If we tried to fill all 40,000 we’d never get where we need. … We have to concentrate on, I think, four areas: primary care, internists, mental health workers and women’s health.”

    He added that this year’s Mission Act legislation, which President Donald Trump signed in June, will give him more power to raise pay and forgive student loans to attract more medical professionals.

    The agency has stepped up hiring in the past two years, Wilkie said, in response to a 2016 Government Accountability Office report that found that VHA lost an increasing number of employees each year between 2011 and 2015.

    In the five clinical occupations with the worst shortages, including physicians, registered nurses and psychologists, VHA’s employee losses grew from about 5,900 in 2011 to about 7,700 in 2015. Voluntary resignations and retirements were the primary drivers.

    “VHA remains fully engaged in a fiercely competitive clinical recruitment market,” the agency said in a statement about the vacancy data. The VA did not respond to requests from Stateline for further comment.

    Staffing vacancies have contributed to recent scandals involving long wait times for care — some Veterans died while waiting for appointments — and the falsifying of wait-time data to deflect scrutiny.

    Hiring woes continued into 2017, a GAO report said, in part because a federal hiring freeze ordered by Trump limited the agency’s ability to hire doctors. Doctors were exempt from the freeze, but there weren’t enough personnel workers to recruit and hire them, the report concluded, and some were not well-trained to do the job.

    The shortage of trained recruiters undermines the VHA’s effectiveness, the report stated, and “impedes its ability to improve delivery of health care access to Veterans.”

    A 2016 report from the congressionally appointed Commission on Care found that VHA doctors and nurses were cleaning offices and doing paperwork because of inadequate numbers of support staff. The commission also detailed a scandal over employees falsifying wait times for service, and some deaths of Veterans on waitlists. An understaffed Phoenix administration system struggled to meet a target of 14-day maximum wait times for appointments.

    The report pointed to “staffing shortages and vacancies” at every level. It also said VHA salaries aren’t competitive, and that the agency “continues to use a talent management approach from the last century.”

    Other reports have described the effects of those shortcomings. In Washington, D.C., the VA inspector general found conditions so chaotic that sometimes doctors had to borrow equipment from other hospitals during treatment, and surgery was postponed because equipment was discovered missing or broken after the patient was anesthetized. Employees told inspectors the problems were caused by a support staff shortage.

    U.S. Sen. Jon Tester, a Montana Democrat, this fall called VHA staffing shortages the most critical issue facing the agency, saying the high rate of vacancies in Montana and elsewhere is hurting care for Veterans.

    “I continue to hear from Veterans across Montana and elsewhere that vacancies and constant turnover in VA facilities impacts how quickly they can get appointments and prevents them from building quality doctor-patient relationships,” Tester, who is running for re-election, wrote in a September letter to Wilkie.

    U.S. Sen. Patty Murray, Democrat of Washington state, told Wilkie at the hearing that the fast-growing Seattle area has been particularly hard hit by service shortages. A clinic on the Kitsap Peninsula, west of Seattle, took years to approve and build and will likely be at capacity when it opens next year, Murray said.

    Nearly a quarter of the staff positions were vacant at VHA facilities in Washington, D.C., and Augusta, Georgia, as of July. But U.S. Sen. Johnny Isakson, the Georgia Republican who sponsored the Mission Act, said this fall that things seem to be improving.

    “I’ve gotten letters from my district, unsolicited, Veterans who used to write me about how we weren’t worth anything because we couldn’t get anything done, [now] thanking me for the efficient way the operation works now,” Isakson said at the September hearing.

    Wilkie, who was confirmed this year, called the job vacancy data “an important step in transparency” but stressed that some vacancies are normal and that some represent new positions created to anticipate future growth. Also, Wilkie said, time to complete a specialist referral has fallen from 19 days in 2014 to about one day this year.

    The agency publishes current wait times for appointments, and some facilities with high vacancy-rates have long waits for appointments: The Augusta, Georgia, Veterans hospital had a 34-day wait for primary care. Chillicothe, Ohio’s hospital, with one of the country’s lowest vacancy rates, had only a six-day wait.

    But average wait times are high even in some hospitals with low vacancies — the Honolulu hospital has only about a 2 percent vacancy rate, the lowest in the country, but its average wait time — 39 days — is one of the highest.

    That’s still a considerable improvement from 2014 when it was the nation’s worst at 130 days, a statistic that prompted Hawaii lawmakers to call for a shakeup. An inspector general report in 2016 said the Honolulu facility hired more doctors and extended clinic hours to get most new appointments scheduled within 30 days.

    Source

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