Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative.

OBJECTIVE: Carotid endarterectomy (CEA) is among the most commonly performed vascular procedures. Some have suggested worse outcomes with contralateral internal carotid artery (ICA) occlusion. We compared patients with and patients without contralateral ICA occlusion using the Society for Vascular Surgery Vascular Quality Initiative database. METHODS: Deidentified data were obtained from the Vascular Quality Initiative. Patients with prior ipsilateral or contralateral CEA, carotid stenting, combined CEA and coronary artery bypass graft, or <1-year follow-up were excluded, yielding 1737 patients with and 45,179 patients without contralateral ICA occlusion. Groups were compared with univariate tests, and differences identified in univariate testing were entered into multivariate models to identify independent predictors of outcomes and in particular whether contralateral ICA occlusion is an independent predictor of outcomes. RESULTS: Patients with contralateral ICA occlusion were younger and more likely to be smokers; they were more likely to have chronic obstructive pulmonary disease, preoperative neurologic symptoms (56% vs 47%), nonelective CEA (16% vs 13%), and shunt placement (75% vs 53%; all P < .001). The 30-day ipsilateral stroke risk was 1.3% with vs 0.7% without contralateral ICA occlusion (P = .004). The 30-day and 1-year survival estimates were 99.0% ± 0.5% and 94.1% ± 1.1% with vs 99.6% ± 0.1% and 96.0% ± 0.2% without contralateral ICA occlusion (log-rank, P < .001). Logistic regression analysis identified prior neurologic event (P = .046), nonelective surgery (P = .047), absence of coronary artery disease (P = .035), and preoperative angiotensin-converting enzyme inhibitor use (P = .029) to be associated with 30-day ipsilateral stroke risk, but contralateral ICA occlusion remained an independent predictor in that model (odds ratio, 2.29; P = .026). However, after adjustment for other factors (Cox proportional hazards), risk of ipsilateral stroke (including perioperative) during follow-up was not significantly greater with contralateral ICA occlusion (hazard ratio, 1.21; P = .32). Results comparing propensity score-matched cohorts mirrored those from the larger data set. CONCLUSIONS: This study demonstrates likely clinically insignificant differences in early stroke or death in comparing CEA patients with and those without contralateral ICA occlusion. After adjustment for other factors, contralateral ICA occlusion was not associated with a greater risk of ipsilateral stroke (including perioperative) in longer follow-up. Mortality was greater with contralateral ICA occlusion, and this difference was more pronounced at 1 year despite younger age of the contralateral ICA occlusion group. CEA risk remains low even in the presence of contralateral ICA occlusion and appears to be explained at least in part by other factors. CEA should still be considered appropriate in the face of contralateral ICA occlusion.

Comparing multicomponent interventions to improve skin care behaviors and prevent recurrence in veterans hospitalized for severe pressure ulcers.

OBJECTIVE: To compare a multicomponent motivational interviewing (MI)/self-management (SM) intervention with a multicomponent education intervention to improve skin-protective behaviors and prevent skin worsening in veterans with spinal cord injury (SCI) hospitalized for severe pressure ulcers (PrUs). DESIGN: Single-blinded, prospective, randomized controlled trial. SETTING: Six Veterans Affairs SCI centers. PARTICIPANTS: Veterans admitted for a severe (stage III/IV) PrU were followed up to 6 months postdischarge. INTERVENTION: Telephone-based individual MI counseling plus SM skills group (SM+MI; n=71) versus an active control group of telephone-based individual educational counseling plus group education (n=72). MAIN OUTCOME MEASURES: Self-reported skin-protective behaviors, objective skin worsening. RESULTS: Intention-to-treat analyses found nonsignificant increases in skin behaviors in the SM+MI versus education control intervention arms at 3 and 6 months. The difference in behaviors used between SM+MI and education control intervention participants was 4.6% (95% confidence interval [CI], -11.3 to 2.7) (0-3mo) and 3.0% (95% CI, -8.7 to 3.9) (0-6mo). High rates of skin worsening were observed (n=74, 51.7%), usually within 3 months postdischarge and most frequently within the month postdischarge. Skin worsening, skin-related visits, and readmissions did not differ by study arm. Study limitations are presented. CONCLUSIONS: For persons with chronic SCI and severe PrUs, complicated by multiple comorbidities, a primary focus on improving patient behavior is likely insufficient to address the complex problem of PrUs in SCI. More health care systems-level changes such as collaborative care may be needed to reduce PrU recurrence, especially in this era in which many people are discharged from the hospital unhealed or with little sitting tolerance.

Healthcare utilization following mild traumatic brain injury in female veterans.

BACKGROUND: Mild traumatic brain injury (TBI) is a significant problem for Veterans. Gender differences in mild TBI outcomes such as return-to-work, resolution of symptoms and mental health diagnoses have been reported. The purpose of the study is to characterize gender differences in VA healthcare utilization in the year following mild TBI diagnosis. METHODS: This was a retrospective database study of 12 144 Veterans diagnosed with mild TBI in fiscal year 2008 and their healthcare utilization in the following year. RESULTS: The mean age was 43.6 ± 17 and the majority were men (94.1%). Overall, women had more outpatient utilization than men with mild TBI (mean: 48 vs. 37 visits; p ≤ 0.001). Adjusted analyses indicated that women had a rate of outpatient utilization 25% higher than men (IRR = 1.25, 95% CI = 1.17-1.33). It was found that 13.6% of the difference in outpatient utilization by gender could be explained by other factors such as race, age, marital status, geographic location and illness burden. CONCLUSION: Male Veterans had less outpatient utilization than females in the year following mild TBI diagnosis. Gender and other factors only accounted for a small portion of the differences observed; therefore, gender only partially accounts for differences in healthcare utilization following mild TBI.

Colonoscopy is high yield in spinal cord injury.

OBJECTIVES/BACKGROUND: Colorectal cancer (CRC) can be prevented by routine colonoscopy. CRC screening in special populations, e.g. spinal cord injury and disorders, presents unique barriers and, potentially, a higher risk of complications. We were concerned about potentially higher risks of complications and sought to determine the safety of colonoscopy. METHODS: Retrospective observational design using medical record review for 311 patients who underwent 368 colonoscopies from two large VA SCI centers from 1997-2008. Patient demographics and peri-procedural characteristics, including indication, bowel prep quality, and pathological findings are presented. Descriptive statistics are presented. RESULTS: The population was predominantly male and Caucasian, and 199 (64%) had high-level injuries (T6 or above). Median age at colonoscopy was 61 years (interquartile range 53-69). Just <1/2 of the colonoscopies were diagnostic, usually for evidence of rectal bleeding. Although a majority of colonoscopies were reported as poorly prepped, the proportion that were adequately prepped increased over time (from 3.7 to 61.3%, P = <0.0001). Of the 146 polyps removed, 101 (69%) were adenomas or carcinomas. Ten subjects had 11 complications, none of which required surgical intervention. CONCLUSIONS: Although providing quality colonoscopic care in this population is labor intensive, the data suggests that it appears safe and therapeutically beneficial. The results indicate that the risk of screening is outweighed by the likelihood of finding polyps. Recognition of the benefit of colonoscopy in this population may have improved bowel prep and reporting over time. Spinal cord injury providers should continue to offer screening or diagnostic colonoscopy to their patients when indicated, while being aware of the special challenges that they face.

Antibiotic prescribing trends in the emergency department for veterans with spinal cord injury and disorder 2002-2007.

OBJECTIVE: Clinical guidelines exist to promote antibiotic stewardship, particularly in ambulatory care settings such as the emergency department (ED). However, there is limited evidence on prescribing practice for persons with spinal cord injury and disorder (SCI/D). The goal of this study was to assess trends in antibiotic prescribing in the ED setting for persons with SCI/D. DESIGN: A retrospective dynamic cohort study design. SETTING: ED visits that did not result in same day hospitalization over 6 years (fiscal year (FY) 2002-FY2007) in Department of Veterans Affairs (VA) facilities Participants Veterans with SCI/D. OUTCOME MEASURES: VA clinical and administrative databases were used to identify the cohort and to obtain demographics, diagnoses, and medications. The rate of antibiotic prescribing for ED visits was defined as the number of antibiotics/total ED visits. RESULTS: Veterans with SCI/D had 21 934 ED visits and 5887 antibiotics prescribed over the study period (rate of 268.4 prescriptions/1000 visits). The antibiotic prescribing rate increased from 238.8/1000 visits in FY2002 to 310.8/1000 visits in FY2007 (P < 0.0001). This increase in the rate of prescribing was seen across all patient demographics and factors assessed. CONCLUSION: Although clinical guidelines for judicious use of antibiotics in persons with SCI/D have been disseminated to providers, antibiotic prescribing in an ED setting is high and continuing to rise in this population.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population. OBJECTIVE: To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D. METHODS: Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes. PARTICIPANTS: Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated. RESULTS: Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D. CONCLUSIONS: SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Guideline-recommended management of community-acquired pneumonia in veterans with spinal cord injury.

BACKGROUND: Pneumonia is a leading cause of death in persons with spinal cord injuries and disorders (SCI/D), but little is known about guideline-based management for this disease in persons with SCI/D. OBJECTIVES: The goal of this study was to describe guideline-based medical care for community-acquired pneumonia (CAP) in veterans with SCI/D. METHODS: A retrospective medical record review was conducted at 7 Department of Veterans Affairs (VA) medical centers where veterans with SCI/D and CAP between 2005 and 2008 were included. Outcomes assessed were receipt of blood or sputum culture, antibiotic timeliness, appropriateness of empiric antibiotic treatment, and vaccination. RESULTS: In 70 patients, 77 CAP episodes occurred and 83.1% were treated in the inpatient setting. The average age was 70.0 years and 64.9% had tetraplegia. Sputum culture was completed in 24.7% and blood culture in 59.7% of cases. Of inpatients, 79.7% had antibiotic treatment within 8 hours and 45.1% received guideline-recommended empirical antibiotics. More than 90% of inpatients received antibiotic treatment within 3 days of presentation and 78.1% received recommended treatment. The rates of pneumococcal pneumonia (89.9%) and influenza (79.7%) vaccinations were high in CAP cases. CONCLUSIONS: Diagnostic testing and early guideline-recommended treatment is variable in veterans with SCI/D and CAP. However vaccination against influenza and pneumococcal pneumonia is high. Specific guidelines for management of CAP in SCI/D patients may be needed, which reflect the unique risk factors and needs of this population. These data can be used as a benchmark for improvements in care processes for treating and managing CAP in persons with SCI/D.

Providers' beliefs and behaviors regarding antibiotic prescribing and antibiotic resistance in persons with spinal cord injury or disorder.

CONTEXT: Persons with spinal cord injury or disorder (SCI/D) are at increased risk for antibiotic resistance because of recurrent infections and subsequent use of antibiotics. However, there are no studies focused on providers who care for these patients and their perceptions regarding antibiotic use and resistance. OBJECTIVE: To characterize SCI/D provider behavior and attitudes about antibiotic prescribing and resistance. DESIGN/METHODS: Anonymous internet-based, cross-sectional survey. PARTICIPANTS: A total of 314 SCI/D clinicians who prescribe antibiotics (physicians, physician assistants, and nurse practitioners). RESULTS: A total of 118 providers responded (37.6% response rate) including 80 physicians, 20 nurse practitioners, and 18 physician assistants. The majority of respondents agreed with statements regarding the societal impact of antibiotic resistance; only 17.8% agreed that they prescribed antibiotics more than they should, but 61.0% agreed that patient demand was a major reason for prescribing unnecessary antibiotics. The most frequent problematic organisms reported were: methicillin-resistant Staphylococcus aureus (83.1%), multidrug-resistant Pseudomonas (61.0%), and Clostridium difficile (57.6%). The most frequent antibiotics selected for outpatient treatment of community-acquired pneumonia treatment, based on a clinical scenario were azithromycin (36.4%) and respiratory fluoroquinolones (22.9%). CONCLUSION: These data show that the respondents are aware of and concerned with the problem of antibiotic resistance in their practice. Clinician respondents also endorsed the need to improve their own knowledge and that of their colleagues regarding appropriate antibiotic prescribing. These findings suggest that interventions should focus on provider education, particularly regarding appropriate antibiotic prescribing.

Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI.

OBJECTIVE: Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters. DESIGN/SETTING/PARTICIPANTS: Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011. OUTCOME MEASURES: Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented). RESULTS: Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants' were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk. CONCLUSION: Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention.

Influenza antiviral treatment in spinal cord injury patients, 2007-2010.

OBJECTIVE: This study assessed antiviral medication use for treatment of influenza-like illness (ILI) in Veterans with spinal cord injury or disorder (SCI/D) and examined whether antiviral prescribing improved over time. DESIGN: Retrospective cohort study of Department of Veterans Affairs (VA) facilities. PARTICIPANTS: Veterans with SCI/D and matched non-SCI/D controls (matched by facility and date of visit/admission) who were diagnosed by a clinician with ILI during the period 1 October 2007 to 31 May 2010. MAIN OUTCOME MEASURES: Antiviral receipt and appropriateness were examined. Appropriate antiviral prescribing was defined as patients who received an antiviral medication within 2 days of collection of a sample for diagnostic testing or within 2 days of symptom onset. RESULTS: We identified 101 influenza visits/admissions for veterans with SCI/D and 123 for controls. Antiviral prescribing for Veterans with SCI/D increased from 37.1% in 2007/2008 to 67.6% in 2009/2010 (P = 0.01) and appropriate antiviral prescribing increased from 20.0 to 41.2% (P = 0.05). Predictors of antiviral prescribing included being treated in the 2009/2010 influenza season (vs. 2007/2008) and having a cough. Fever, aches/myalgia, or a positive influenza test was associated with appropriate antiviral treatment. SCI/D was an independent predictor of receiving antiviral treatment (adjusted odds ratio = 1.16, 95% confidence interval 1.04-1.29), but having SCI/D was not associated with receiving appropriate treatment. CONCLUSIONS: Influenza antiviral prescribing increased over time and in a larger proportion in veterans with SCI/D (vs. controls). This suggests that providers treating patients with SCI/D recognize treatment guidelines and their importance in a high-risk population. Continued efforts are needed to improve appropriate influenza antiviral prescribing.

Medication acquisition across systems of care and patient-provider communication among older veterans.

PURPOSE: The results of a survey assessing Medicare Part D enrollment, the use of pharmacotherapies for chronic diseases, and other medication-use issues in a population of elderly military veterans are presented. METHODS: Medicare-eligible (i.e., ≥65 years of age) patients with documented recent service use at a single Veterans Affairs (VA) medical center were targeted for a mail survey. Women were oversampled (20%) to ensure an adequate sample size; the sample was weighted to adjust for this oversampling. Usable survey data were received from 458 survey respondents. RESULTS: Nearly all respondents (93.2%) reported having one or more chronic conditions; of those, 93.3% reported regular use of multiple drug therapies, and 30.1% reported using medications prescribed by both VA and non-VA providers for the same chronic condition. About half of the survey respondents reported at least one office visit with a non-VA physician during the previous year, and 55.8% reported obtaining medications from non-VA pharmacies. More than half (54.1%) of the respondents reported non-VA medication coverage, with 21.2% indicating they were enrolled in Medicare Part D. Among the respondents who reported obtaining medications from non-VA pharmacies, substantial proportions reported discussing those medications with VA physicians never (38.4%) or infrequently (15.7%). CONCLUSION: Although large proportions of Medicare-eligible veterans take multiple medications and use non-VA health care services and pharmacies, many do not discuss medications obtained outside the VA system with VA physicians, suggesting that increased efforts to enhance provider-patient communication and medication reconciliation across VA and non-VA systems of care may be warranted.

Knowledge and use of antimicrobial stewardship resources by spinal cord injury providers.

OBJECTIVE: To assess the knowledge and the use of antimicrobial stewardship resources, such as hospital antibiograms and infectious disease consultants, by spinal cord injury or disorder (SCI/D) providers. DESIGN AND SETTING: Anonymous Internet-based, cross-sectional survey. PARTICIPANTS: A total of 314 SCI/D physicians, nurse practitioners, and physician assistants who prescribe antibiotics were invited to complete a survey. MAIN OUTCOME MEASUREMENTS: Knowledge of and behaviors related to antibiograms and infectious disease (ID) consults. RESULTS: A total of 118 providers (80 physicians, 20 nurse practitioners, 18 physician assistants) completed the survey (37.6% response rate). Approximately one-third of respondents indicated that they did not have access to (11.0%) or were unsure of (28.0%) the existence of facility antibiograms. Half of the providers indicated that they never used antibiograms to determine treatment for their SCI/D patients. Respondent factors associated with viewing facility antibiograms were older age, employment at SCI/D specialty centers, a longer duration since completion of training, and years of SCI/D patient care. Nearly all respondents (95%) indicated that they believed that improving access to antibiotic prescribing data or antibiograms would reduce antibiotic resistance. More than one-third reported that they never or seldom used ID consults. CONCLUSIONS: A significant portion of SCI/D providers who prescribe antibiotics do not have access to facility antibiograms or are unaware of their existence and thus could not use them for determining antibiotic treatment. Interventions could include formal education of providers on how to access antibiograms and the use of ID physicians as a resource, as well as providing technologic support, such as electronic facility-level antibiograms as part of the medical record system, which can be easily identified if a provider is making a decision on an antibiotic.