Introduction and Objective: Hypertriglyceridemia (HTG) is an independent risk factor for cardiovascular (CV) disease with few pharmacologic options. Current dietary management of HTG includes whole grains, oats, legumes, and fruits, however restricting these carb-rich foods reduces triglycerides (Trigs) in the context of WFKD. The magnitude of reduction of Trigs with WKFD at different levels of baseline HTG is not known. Methods: Virta remotely offers WKFD to patients with metabolic disease. From among our real-world population, a random sample of patients with enrollment (E) Trigs 150 to 499 mg/dl (ETrigs150, n=500) and ≥500 mg/dl (ETrigs500, n=500) with 6 month (6m) follow-up labs were identified to explore changes in dyslipidemia, weight, A1c over time. Results: The table shows the characteristics of each cohort at E, and weight, A1c, and lipids at E and 6m. Trigs, nonHDL, and Tg-HDL ratio dropped 30.4%, 6.5%, and 34.2% in ETrigs150, and 56.2%, 22.7%, and 49.8% in ETrigs500, respectively (p-values<0.001). There was no change in LDLc in ETrigs150, and LDLc increased slightly within the normal range in ETrigs500, while non-HDL and total cholesterol dropped significantly. These changes suggest improved lipid metabolism. Conclusion: WKFD delivered remotely improves HTG, and appears to be a highly effective way to address both CV risk and insulin resistance non-pharmacologically. Studies of clinical CV endpoints are warranted. Disclosure C.G.P. Roberts: Employee; Virta Health Corp. Stock/Shareholder; Virta Health Corp. S.J. Athinarayanan: Employee; Virta Health Corp.
The nursing shortage has existed for a long time, well before the COVID-19 pandemic. During the pandemic, our health care system came close to collapsing, in part because of a shortage of health care workers, and the nursing shortage will get worse because of nurses retiring, nurses experiencing high levels of burnout, nurse recruitment challenges, widening wage gaps among nurse positions, and hospital profit margins.In the United States, 40% of nurses are older than 50 years and more than 1 million nurses are estimated to retire by 2030.1 There were approximately 3 million registered nurses in May 2021,2 so the health care industry could lose nearly one-third of registered nurses to retirement over the next 7 years. Furthermore, baby boomers are reaching retirement age, a phenomenon referred to as the "Silver Tsunami."3 The elderly population (>65 years) will total an estimated 78 million people and will outnumber children for the first time in history by 2035,4 resulting in an increased burden on a shrinking health care workforce.In a 2021 survey,5 half of the nurses reported having considered leaving the profession, citing staffing shortages, feeling underpaid and underappreciated, mental health reasons, and a lack of work-life balance. In a 2021 study, Lasater et al6 found that more than half of nurses experienced burnout. According to a survey conducted by the American Association of Critical-Care Nurses, 92% of nurses believe their careers as nurses will be "shorter than intended," and 66% are considering leaving nursing because of their experiences during the pandemic.7According to the US Bureau of Labor Statistics, the United States will have to add 203 700 nurses annually for the next decade in order to meet the market need.8 A limiting factor to nurse recruitment is the number of new nurse graduates—a lack of faculty with clinical experience, clinical sites for hands-on experience, classroom space, and clinical preceptors caused more than 75 000 nursing school applicants to be turned away in 2018.9 After nurse graduates enter the workforce, many quickly move to nursing professions in less stressful environments such as administration.10In 2021, the national average salary of full-time registered nurses was $77 600 per year, or about $38 per hour.2 In 2023, the national average salary for travel nurses is $88 320, or about $51 per hour.11 Travel nurses are typically eligible for sign-on bonuses, travel stipends, and housing allowances; some also receive benefit packages.11 Staffing agencies usually bill the hospital from $65 to $85 per hour for travel nurses.12 The difference between the bill rate (what the agency pays the hospital) and the pay rate (what the employee is paid) ranges from 32% to 65%.13 Kansas, Ohio, Oregon, Illinois, and Pennsylvania are pursuing legislation to set maximum rates for travel nurses, which has been done in Minnesota.14 Despite the high cost of travel nurses, the demand keeps increasing,15 widening the wage gap between full-time nurses and travel nurses further.According to the Centers for Medicare & Medicaid Services, the national health expenditure grew to $4.3 trillion, or $12 914 per person, in 2021, amounting to 18.3% of the gross domestic product.16 The hospital industry is responsible for 5.8% of the gross domestic product, or nearly one-third of annual health care revenue.17 Despite being among the most profitable sectors in the US economy, hospital systems estimated a revenue loss between $53 billion and $122 billion in 2021.18 Conversely, some reports have suggested that the US hospital market size increased between 2017 and 2022, despite setbacks related to the pandemic.17Current recruitment practices are not up to the task of filling the applicant pool required to meet the future demand. The wage gap incentivizes nurses to "job hop" rather than remain in their current position. Many talented and experienced nurses are burned out and either take early retirement or switch their clinical role to a nonclinical role. The nurses who leave the profession are taking with them the expertise and skills learned during their clinical tenure; most are not sharing their expertise among peers, colleagues, graduates, trainees, and students. We need to advocate for structural solutions and consider ways nurses can pass along their knowledge. Many nurses who leave the profession may not realize that they are qualified to teach in the laboratory or clinical setting. Moreover, an educator's role may be a flexible option for nurse retirees as part-time positions are often available. Lastly, retired nurses have opportunities to serve as guest faculty in nursing schools; be keynote speakers and session speakers at various state, national, and international conferences; and participate in community-based educational settings.We must act and we must act soon! Let us save our nursing workforce and advocate for them so that they have an environment in which to thrive, succeed, and mentor.
Socioeconomic conditions of one's community have been attributed to disparities in diabetes outcomes and management practices. Among a random sample (n=19955) of people with type 2 diabetes receiving care at a nationwide telemedicine clinic utilizing a carbohydrate restricted nutritional approach and continuous remote care model (CR-CRCM), we explored A1c and medication utilization by area deprivation index quintile (Q). Upon enrollment, patients residing in more disadvantaged areas (Q4, Q5) had higher A1c compared to the least disadvantaged area (Q1; 7.8% vs 7.7%, p<0.01), and insulin (INS) and sulfonylureas (SU), but not other medication classes, were prescribed to a greater proportion of patients living in Q5 (25% INS, 23% SU) compared to Q1 (18% INS, 18% SU) and Q2 (21% INS, 19% SU) after accounting for differences in age, sex, baseline BMI, baseline INS use (when appropriate), and race and ethnicity (p<0.05). After one year in clinic, no differences in the prescription of medication classes between Q were observed, except for INS, where greater use remained only in Q5 than Q1 (14% vs 10%, p=0.011); among those remaining on INS, dose was reduced by 49-58% across all Q (p<0.001). Differences in SU use were no longer present; 77-83% fewer SU were prescribed across Q. Differences in A1c between Q4 (6.6%) and Q5 (6.7%) vs Q1 (6.5%) remained (p<0.001), though all groups achieved significant reductions in A1c of 1.1-1.2% (all p<0.001) concurrent with reduced prescription of all diabetes medication (from 1.7-1.8 to 1.1-1.2 medication classes per person). Across all levels of socioeconomic disadvantage, patients achieved clinically and statistically meaningful reductions in A1c and medication. Higher rates of SU use among patients residing in more disadvantaged areas were mitigated through a CR-CRCM to improve glycemia. Further, these data suggest a CR-CRCM may overcome financial barriers to optimal diabetes management through reduced need for medication. Disclosure A.L.Mckenzie: Employee; Virta Health Corp., Stock/Shareholder; Virta Health Corp. S.J.Athinarayanan: Employee; Virta Health Corp.
