Using Geographic Information System Mapping in Emergency Management: Expanding the Role of Nurses in Home Based Primary Care.

The Veterans Health Administration Home Based Primary Care (VHA-HBPC) program serves Veterans with complex, chronic conditions. Emergency management is a concern for VHA-HBPC programs. Geographic information system (GIS) mapping has been implemented for local program operations in 30 locations. An evaluation assessed GIS mapping as a tool in emergency management, including frontline nurses' and nurse leaders' experiences. Nurses' roles included making and using maps for preparedness and response. Maps provided valuable information, including locations of vulnerable patients (eg, ventilator dependent), community emergency resources, and environmental threats (eg, hurricane). Nurses' willingness to embrace this new technology and skill set was notable.

Health Coaching: A Preliminary Report on the Effects in Traumatic Brain Injury/Polytrauma Patients.

BACKGROUND: Failure to adhere to treatment recommendations has significant impact on the health outcomes of the individual and health care systems. Health coaching is a promising care model that has gained interest in the medical field. This study focused on the impact of health coaching on health behaviors that may have direct impact on successful patient outcomes. PRIMARY STUDY OBJECTIVE: The objective of this study was to assess the impact of health coaching administered through the Polytrauma Integrative Medicine Initiative (PIMI). METHODS/DESIGN: This study was a quasiexperimental cohort study. SETTING: This study occurred at a specialized polytrauma rehabilitation center. PARTICIPANTS: Participants were divided into 3 cohorts: (1) 33 patients who served through PIMI enrollment, (2) 22 patients who declined PIMI, and (3) a control cohort of 30 random patients who were not referred to PIMI. Patients were primarily male active duty or veteran military personnel. INTERVENTION: The intervention consisted of personalized health coaching by trained, certified personnel. PRIMARY OUTCOME MEASURES: Outcome measures included the following (1) Self-assessment: utilizing the Personal Health Inventory (PHI) at enrollment and at 3 mo; (2) treatment adherence: the percentage of scheduled appointments fulfilled by patients; and (3) post hoc analysis: for no-show and cancellation rates; 2-tailed paired t tests for PHI data and post hoc within groups; 2-tailed independent samples t tests for treatment adherence percentages and post hoc between groups. RESULTS: There was no significant difference in treatment adherence rates between the 3 cohorts (all P > .45). PIMI patients had significantly higher cancellation rates than no-show rates for both clinical, 20.8%/5%, and coaching appointments, 17.3%/7.5%, (P < .05). PIMI patients had significantly lower no-show rates, 5%, than control patients, 15.8% (P = .007). PHI data suggest PIMI patients believe they are making improvements in many areas of health coaching focus. CONCLUSION: Low cohort numbers are a concern. There was no difference for treatment adherence rates for health coaching compared with no health coaching. Select variables such as cancellation and no-show appointment rates may better capture the impact of health coaching on patient behavior and clinical resource utilization.

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 2.

OBJECTIVE: To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke. DESIGN: Retrospective cohort study. SETTING: Veterans Affairs Medical Centers (VAMCs) throughout the United States. PARTICIPANTS: Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the ß coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery. MAIN OUTCOME MEASURE: Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs. RESULTS: Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (<60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16). CONCLUSION: Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

Comprehensive versus consultative rehabilitation services postacute stroke: Outcomes differ.

Comprehensive rehabilitation services postacute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services postacute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr posthospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1-yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1-yr survival.

Factors associated with home discharge among veterans with stroke.

OBJECTIVE: To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs. DESIGN: Retrospective observational study. SETTING: Veterans Affairs facilities nationwide. PARTICIPANTS: Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Discharge location after hospitalization. RESULTS: There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11-1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03-.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50-.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63-.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07-1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76-.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77-.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78-.97), and serious nutritional compromise (OR=.49; 95% CI=.40-.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge. CONCLUSIONS: We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.

Development and validation of a discharge planning index for achieving home discharge after hospitalization for acute stroke among those who received rehabilitation services.

OBJECTIVE: The aim of this study was to develop an index for establishing the probability of being discharged home after hospitalization for acute stroke using information about previous living circumstances, comorbidities, hospital course, and the physical grades and cognitive stages of independence achieved. DESIGN: This is a longitudinal observational population-based study. All 6515 persons treated for acute stroke who received rehabilitation services in 110 Veterans Affairs facilities within a 2-yr period were included. RESULTS: There were eight independent predictors of home discharge identified, and points were assigned through logistic regression: married (2 points); location before hospitalization (extended care = 0 points, other hospital = 9 points, home = 11 points); discharge physical grade (grade I, II, or III = 0 points; grade IV or V = 3 points; grade VI or VII = 5 points); discharge cognitive stage (stage I = 0 points; stage II, III, IV, or V = 3 points; stage VI or VII = 5 points); and absence of liver disease (2 points), mechanical ventilation (3 points), nonoral feeding (2 points), and intensive care unit admission (1 point). The points were added for all present factors to calculate scores. The probabilities of home discharge ranged from 65.03% in the least likely (≤21 points) to 98.24% in the most likely group (≥27 points). CONCLUSIONS: The treatment team might apply prognostic estimates from this index in discharge planning and functional goal setting after initial physical medicine and rehabilitation assessment.

One-year all-cause mortality after stroke: a prediction model.

OBJECTIVE: By using data from Department of Veterans Affairs (VA) national databases, this article presents and internally validates a 1-year all-cause mortality prediction index after hospitalization for acute stroke. DESIGN: An observational cohort. SETTING: VA medical centers. PARTICIPANTS: Veterans with a diagnosis of a new stroke who were discharged between October 1, 2006, and September 30, 2008. MAIN OUTCOME MEASURE: Death due to any cause that occurred between the index hospital discharge date and the 1-year anniversary of that date. RESULTS: Within 1-year after discharge, 1542 (12.3%) of the total 12,565 patients had died. Seventeen risk factors known at the point of hospital discharge remained in the predictive model of 1-year postdischarge mortality after backward selection, including advanced age, admission from extended care, type of stroke, 8 comorbid conditions, 4 types of procedures that occurred during the index hospitalization, hospital length of stay (longer than 3 weeks), and discharge location. We assigned a score to each variable in the final model and a risk score was determined for each patient by adding up the points for all risk factors present. According to these risk scores, the patients were divided into approximate quartiles that yielded low, moderate, high, and highest mortality likelihood strata. The risk of 1-year mortality ranged from 2.24% in the lowest quartile to 29.50% in the highest quartile in the derivation cohort and from 2.11%-30.77% in the validation cohort. Model discrimination demonstrated an area under the receiver operating characteristic curve of 0.785 in the derivation cohort and 0.787 in the validation cohort. The Hosmer-Lemeshow goodness of fit indicated that the model fit was adequate (P = .69). CONCLUSION: When using readily available data, a simple index that stratifies stroke patients at hospital discharge according to low, moderate, high, and highest likelihood of all-cause 1-year mortality is feasible and can inform the postdischarge planning process, depending on level of risk.

Factors influencing receipt of early rehabilitation after stroke.

OBJECTIVE: To identify patient-level characteristics associated with rehabilitation during the acute poststroke phase. DESIGN: Retrospective cohort. Generalized estimating equations modeled the likelihood of rehabilitation during the index hospitalization to account for patient clusters. SETTING: Rehabilitation facilities. PARTICIPANTS: Sample included veterans (N=9681; average age, 68.7y; 97.4% men) diagnosed with new stroke discharged from Veterans Affairs hospitals between October 1, 2006, and September 30, 2008. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Receipt of rehabilitation services. RESULTS: Of the total cohort, 73% received some type of rehabilitation. After adjustment, stroke patients with cerebral arteries occlusion were most likely to receive rehabilitation compared with other stroke types (P<.001). Patients with prestroke conditions of metastatic cancer (odds ratio [OR]=.68, P<.001) and psychosis (OR=.90, P=.045) were less likely to have rehabilitation, whereas those with hypertension (OR=1.26, P<.001) and other neurologic disorders (OR=1.29, P<.001) were more likely. Compared with patients admitted from home, patients transferred from a non-Veterans Affairs hospital (OR=1.4, P<.004) were more likely to receive rehabilitation, whereas patients admitted from extended care (OR=.59, P<.001) were less likely. Married veterans were less likely to receive rehabilitation services (OR=.87, P<.001) than unmarried veterans. CONCLUSIONS: Within the Veterans Health Administration, initiating rehabilitation in the acute phase poststroke appears to be influenced by patient clinical characteristics and living circumstances.

Initial physical grades and cognitive stages after acute stroke: who receives comprehensive rehabilitation services?

OBJECTIVES: To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. DESIGN: An observational study. SETTING: Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. PATIENTS: The sample included 8,783 veterans who were assessed by PM&R staff. METHODS: Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent "I" through intermediate "II, III, IV, V, or VI," and ended with the highest at total independence "VII." To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors. MAIN OUTCOME MEASUREMENTS: The decision to admit patients to an SRU for comprehensive rehabilitation. RESULTS: Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. CONCLUSIONS: Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.

Factors associated with home discharge after rehabilitation among male veterans with lower extremity amputation.

OBJECTIVE: To determine the patient-, treatment-, and facility-level factors that are associated with home discharge among male veterans with lower extremity amputation who received inpatient rehabilitation after surgery. DESIGN: A retrospective observational study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: This study included 1480 male veterans. METHODS: Generalized estimating equation models were used to model the likelihood of home discharge to account for within-facility clustering. We reported odds ratios (ORs) and 95% confidence intervals (95% CIs). MAIN OUTCOME MEASUREMENT: Discharged to home. RESULTS: There were a total of 1163 (78.6%) veterans who were discharged home after the surgical hospitalization, compared with other locations. Patients who were married were more likely to be discharged home compared with patients who were not married (OR = 1.51, 95% CI = 1.14-1.99, P < .01). Compared with being transferred from another hospital or extended care, patients who were admitted from home were far more likely to be discharged home (OR = 8.43, 95% CI = 5.48-12.96, P < .0001). Patients with evidence of local significant infection were less likely to be discharged home (OR = 0.57, 95% CI = 0.39-0.83, P < .01), as were patients with evidence of congestive heart failure (OR = 0.62, 95% CI = 0.45-0.85, P < .01) or depression (OR = 0.63, 95% CI = 0.40-0.98, P = .04). Veterans with greater discharge motor Functional Independence Measure scores were more likely to be discharged home (OR = 1.23, 95% CI = 1.16-1.31 per 10-point increase in discharge Functional Independence Measure motor score, P < .0001). Conversely, patients undergoing procedures for ongoing active cardiac pathology were less likely to be discharged home (OR = 0.55, 95% CI = 0.37-0.81, P < .01). CONCLUSIONS: This study showed a strong association between the sociological factors of marital status and living location before hospitalization and home discharge. The significance of discharge functional status highlights the importance of addressing the expected care burden once patients are discharged home.

Unreliability and error in the military's "gold standard" measure of sexual harassment by education and gender.

The Department of Defense's "gold standard" sexual harassment measure, the Sexual Harassment Core Measure (SHCore), is based on an earlier measure that was developed primarily in college women. Furthermore, the SHCore requires a reading grade level of 9.1. This may be higher than some troops' reading abilities and could generate unreliable estimates of their sexual harassment experiences. Results from 108 male and 96 female soldiers showed that the SHCore's temporal stability and alternate-forms reliability was significantly worse (a) in soldiers without college experience compared to soldiers with college experience and (b) in men compared to women. For men without college experience, almost 80% of the temporal variance in SHCore scores was attributable to error. A plain language version of the SHCore had mixed effects on temporal stability depending on education and gender. The SHCore may be particularly ill suited for evaluating population trends of sexual harassment in military men without college experience.

The association between military sexual stress and psychiatric symptoms after controlling for other stressors.

OBJECTIVE: Several researchers have identified associations between exposure to occupational sexual stressors (e.g., sexual harassment) and severer psychiatric symptoms in military personnel. However, few controlled for participants' exposures to other high-magnitude stressors, which could have confounded results. We examined the unique association between military sexual stress and severity of participants' psychiatric symptoms after controlling for their other high-magnitude stressor experiences. Organizational- and individual-level predictors of military sexual stress were also assessed. METHOD: We surveyed by mail all active duty troops registered in the Department of Veterans Affairs' Enrollment Database (2001-2003). The questionnaire contained well-validated measures. RESULTS: Eighty-four percent responded (total sample N = 611); of these 56% reported at least one sexual stressor exposure. A highly significant association between military sexual stress and psychiatric symptoms attenuated by two thirds and lost statistical significance once other stressor experiences were controlled. Besides sociodemographics, the strongest correlates of military sexual stress were working in an environment perceived to tolerate sexual harassment, reporting severer childhood maltreatment, and reporting more high-magnitude stressors. A gender-stratified analysis generated similar findings for men and women. CONCLUSIONS: Little unique variance in psychiatric symptom reporting was explained by military sexual stressor exposure after controlling for other stressors. Childhood maltreatment and other high-magnitude stressors acted as risk factors for and confounders of military sexual stress. Understanding how and why these stressors inter-relate could lead to better, more effective interventions to reduce them all-and their sequelae. Findings also highlight the need to routinely include men in sexual stress research.

Using the Medicare Current Beneficiary Survey to conduct research on Medicare-eligible veterans.

The Medicare Current Beneficiary Survey (MCBS) is a longitudinal, multipurpose panel survey of a nationally representative sample of Medicare beneficiaries sponsored by the Centers for Medicare and Medicaid Services (CMS). The MCBS serves as a comprehensive data source on self-reported health and socioeconomic status, health insurance, healthcare utilization and costs, and patient satisfaction. CMS uses Medicare claims data to validate self-reported Medicare Fee-For-Service (FFS) utilization. Because the Veterans Health Administration (VHA) does not bill for services, CMS imputes VHA costs. This article addresses the quality of the MCBS dataset for conducting research on Medicare-eligible veterans by addressing the sample's representativeness, quality of self-reported data, and accuracy of imputed VHA cost estimates. We compared demographic data from the 1992 and 2001 National Survey of Veterans (NSV) with the MCBS 1992 and 2001 Cost and Use files. We compared self-reported VHA utilization and CMS's imputed costs with VHA administrative datasets. The VHA's Pharmacy Benefits Management (PBM) database is available from fiscal year (FY) 1999 onward, and the VHA Health Economics Resource Center's (HERC) Average Cost datasets are available from FY1998 onward. While the samples were comparable in terms of age, sex, and race, the MCBS respondents were in better health, less likely to be married, and more likely to be widowed than NSV respondents. MCBS underreporting rates were higher for VHA than Medicare outpatient events. Underreporting and differences between CMS's and HERC's costing methodologies contributed to lower MCBS versus VHA administrative person- and event-level costs. Alternatively, average annual VHA prescription costs per capita were higher in the MCBS than in the PBM data. Differences in socioeconomic characteristics of the NSV and MCBS samples may be attributable to differences in sampling methodologies. Higher underreporting rates for VHA versus Medicare FFS outpatient events are likely due to systemic differences between the VHA and private healthcare sectors. While VHA formulary discounts may not be reflected in MCBS's VHA prescriptions costs, lower PBM prescriptions costs are also due to deficient indirect cost data. Since reliable VHA utilization and cost data existed in either FY1998 or FY1999 onward, study goals include estimating the relative share and/or cost of care provided by Medicare and the VHA. Researchers with access to VHA datasets should consider merging them into the MCBS and replacing self-reported utilization and CMS's imputed costs with VHA administrative data. This replacement would significantly improve the accuracy, quality, and usefulness of the MCBS dataset for policy research.

Prognostic differences for functional recovery after major lower limb amputation: effects of the timing and type of inpatient rehabilitation services in the Veterans Health Administration.

OBJECTIVE: To compare the recovery of mobility and self-care functions among veteran amputees according to the timing and type of rehabilitation services received. DESIGN: Observational study of inpatient rehabilitation care patterns of 2 types (specialized and consultative) with 2 timings (early and late). SETTING: Data from inpatient specialized rehabilitation units (SRUs) and consultative services within 95 Veterans Affairs Medical Centers across the United States during fiscal years 2003 to 2004. PATIENTS: Medical records of 1502 patients who received early or late consultative or specialized rehabilitation. ASSESSMENT OF RISK FACTORS: Hypotheses were established and general categories of negative and positive risk factors specified a priori from available clinical characteristics. Linear mixed effects models were used to model motor Functional Independence Measure (FIM) gain scores on patient-level variables accounting for the correlation within the same facility. MAIN OUTCOME MEASURES: Recovery of activities of daily living (ADLs) and mobility (physical functioning) expressed as the magnitudes of gains in motor FIM scores achieved by rehabilitation discharge. RESULTS: After adjustment, amputees who received specialized rehabilitation had motor FIM gains that were on average 8.0 points greater than those for amputees who received consultative rehabilitation. Although patients whose rehabilitation was delayed until after discharge from the index surgical stay tended to be more clinically complex, they had gains comparable to those of patients who received early rehabilitation. Advanced age, transfemoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower motor FIM gains. The variance for the random effect for facility was statistically significant, suggesting extraneous variation within facility that was not explainable by observed patient-level variables. CONCLUSION: On the basis of this analysis, those patients who receive specialized rehabilitation can be expected to make comparatively greater gains than patients who receive consultative services, regardless of timing and clinical complexity. Findings highlight the need for clinicians to adjust prognostic expectations to both clinical severity and the type of rehabilitation that patients receive.

Local social norms and military sexual stressors: do senior officers' norms matter?

OBJECTIVE: To examine the relative importance of harassment-tolerant norms emanating from troops senior officers, immediate supervisors, and units on troops' sexual stressor experiences and to see whether associations differed by sex. METHOD: Cross-sectional survey of all 681 willing and confirmed active duty troops enrolled in the VA National Enrollment Database between 1998 and 2002. Findings extended an earlier analysis. RESULTS: After adjusting for other significant correlates, senior officers' perceived tolerance of sexual harassment was not associated with the severity of sexual harassment troops reported (p = 0.64) or with the numbers of sexual identity challenges they reported (p = 0.11). Harassment-tolerant norms emanating from troops' units and immediate supervisors were associated with reporting more severe sexual harassment and more sexual identity challenges (all p < 0.003). Findings generalized across sex. CONCLUSIONS: Senior officers' norms did not appear to affect troops' reports of military sexual stressors, but unit norms and immediate supervisors' norms did.