Predictors of lower extremity fracture-related amputation in persons with traumatic spinal cord injury: a case-control study.

STUDY DESIGN: This is a retrospective case-control study. OBJECTIVES: To identify predictors of lower extremity (LE) long bone fracture-related amputation in persons with traumatic spinal cord injury (tSCI). SETTING: US Veterans Health Administration facilities (2005-2015). METHODS: Fracture-amputation sets in Veterans with tSCI were considered for inclusion if medical coding indicated a LE amputation within 365 days following an incident LE fracture. The authors adjudicated each fracture-amputation set by electronic health record review. Controls with incident LE fracture and no subsequent amputation were matched 1:1 with fracture-amputation sets on site and date of fracture (±30 days). Multivariable conditional logistic regression determined odds ratios (OR) and 95% confidence intervals (CI) for potential predictors (motor-complete injury; diabetes mellitus (DM); peripheral vascular disease (PVD); smoking; primary (within 30 days) nonsurgical fracture management; pressure injury and/or infection), controlling for age and race. RESULTS: Forty fracture-amputation sets from 37 Veterans with LE amputations and 40 unique controls were identified. DM (OR = 26; 95% CI, 1.7-382), PVD (OR = 30; 95% CI, 2.5-371), and primary nonsurgical management (OR = 40; 95% CI, 1.5-1,116) were independent predictors of LE fracture-related amputation. CONCLUSIONS: Early and aggressive strategies to prevent DM and PVD in tSCI are needed, as these comorbidities are associated with increased odds of LE fracture-related amputation. Nonsurgical fracture management increased the odds of LE amputation by at least 50%. Further large, prospective studies of fracture management in tSCI are needed to confirm our findings. Physicians and patients should consider the potential increased risk of amputation associated with non-operative management of LE fractures in shared decision making.

"Pathological" fractures in spinal cord injuries and disorders: Insight into International classification of diseases, ninth revision coding.

OBJECTIVE: Analyses of osteoporosis-related fractures in persons with Spinal Cord Injury or Disorder (SCID) using administrative data often exclude pathological fractures (International Classification of Diseases, Ninth Revision (ICD-9) codes 733.1x). We examined how often lower extremity "pathological" fractures were secondary to osteoporosis. DESIGN: Retrospective case-control study, fiscal years 2005-2015. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans with SCID and an ICD-9 code for lower extremity fracture. OUTCOME MEASURES: Clinical and SCID-related characteristics were compared in pathological and non-pathological fractures. A subset of Veterans with lower extremity fracture had data on fracture etiology from prior electronic health record (eHR) review. Of these, all with eHR-confirmed pathological fractures were considered cases. For each case, four unmatched controls with non-pathological fractures from this subset were randomly selected. Fracture etiology was compared between subsample cases and controls. We sought expert opinion from specialists who care for these fractures to understand their perspectives on what constitutes a pathological fracture and narrate our findings. RESULTS: 6,397 Veterans sustained 16,279 lower extremity fractures, including 314 (1.93%) pathological fractures in 264 Veterans. Ten of 13 (76.9%) cases of pathological fracture (76.9%) and 82.4% of non-pathological fractures were secondary to osteoporosis. Of the 19 experts surveyed, only two coded osteoporotic fractures as pathological. CONCLUSION: Most pathological lower extremity fractures by ICD-9 codes in SCID are secondary to osteoporosis. Pathological fractures can be considered for inclusion in epidemiologic studies of osteoporosis in SCID when the risk-benefit profile for the study favors capturing all osteoporotic fractures at the expense of some misclassification.

Risk Factors and Consequences of Lower Extremity Fracture Nonunions in Veterans With Spinal Cord Injury.

We used Veterans Health Administration (VHA) national administrative data files to identify a cohort (fiscal years 2005-2014) of veterans with spinal cord injuries and disorders (SCID) to determine risk factors for and consequences of lower extremity fracture nonunions. Odds ratios (OR) for fracture nonunion were computed using multivariable-adjusted logistic regression models. We identified three risk factors for nonunion: (i) older age (OR = 2.29; 95% confidence interval [CI] 1.21-4.33), (ii) longer duration of SCID (OR = 1.02; 95% CI 1.00-1.04), and (iii) fracture site (distal femur), with OR (comparison distal femur) including distal tibia/fibula (OR = 0.14; 95% CI 0.09-0.24), proximal tibia/fibula (OR = 0.19; 95% CI 0.09-0.38), proximal femur (OR = 0.10; 95% CI 0.04-0.21), and hip (OR = 0.13; 95% CI 0.07-0.26). Nonunions resulted in multiple complications, with upwards of 1/3 developing a pressure injury, 13% osteomyelitis, and almost 25% requiring a subsequent amputation. Our data have identified a high-risk population for fracture nonunion of older veterans with a long duration of SCID who sustain a distal femur fracture. In view of the serious complications of these nonunions, targeted interventions in these high-risk individuals who have any signs of delayed union should be considered. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

Reasons for Initiation and Discontinuation of Pharmacological Therapies for Osteoporosis in Veterans with Spinal Cord Injury and Disorders.

INTRODUCTION: Medications for osteoporosis have not been reported to reduce fracture rates in patients with spinal cord injury and disorders (SCI/D), yet these medications are still prescribed. Clinical decision-making underscoring the initiation and discontinuation of osteoporosis medications in SCI/D remains poorly understood. METHODOLOGY: Veterans with a SCI/D with at least one prescription for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, and teriparatide) who received healthcare within Veterans Affairs (VA) from 2005 to 2015 were identified using VA administrative databases. A 10% subsample of Veterans was selected for electronic health record review. RESULTS: Two hundred and sixty-seven Veterans with 330 prescriptions underwent electronic health record review. Bisphosphonates were the most frequently prescribed medication for osteoporosis (n = 223, 67.6%). Of the 187 Veterans with prescriptions for prevention or treatment of osteoporosis, the primary reason for initiation was Dual Energy X-ray Absorptiometry (DXA) scan with osteopenia or osteoporosis (n = 119, 63.6% of Veterans), primarily at the hip (81.0% of DXAs). The majority (79.0%) of DXAs were "screening tests," with SCI/D being the sole reason for the scan. Fractures (n = 51, 27.3%) and fall risk concerns (n = 29, 15.5%) were other major reasons for initiation. On average, oral bisphosphonates were filled for <3 yr, with medication-related side effects (n = 23, 15.8% of bisphosphonates discontinued), predominately gastrointestinal (n = 17, 73.9% of reported side effects), the most common reason for discontinuation. Drug holidays occurred in 14.3% of 35 oral bisphosphonates used for ≥5 yr. No cases of osteonecrosis of the jaw were found. There was one case of an atypical femoral fracture which could not be confirmed. CONCLUSIONS: The decision to initiate pharmacological therapies in SCI/D is primarily based on osteopenia or osteoporosis at the hip by screening DXAs. Gastrointestinal side effects are the major reason for discontinuation of oral bisphosphonates. New therapies for osteoporosis in SCI/D are needed.

Association of Bisphosphonate Therapy With Incident of Lower Extremity Fractures in Persons With Spinal Cord Injuries or Disorders.

OBJECTIVE: To investigate the association between prescriptions for bisphosphonates; calcium and vitamin D supplements; and receipt of dual-energy x-ray absorptiometry (DXA) screening, and incident fracture risk in men and women with a spinal cord injury (SCI) or disorder (SCID). DESIGN: Propensity-matched case-control analyses. SETTING: United States Veterans Affairs (VA) facilities. PARTICIPANTS: A total of 7989 men and 849 women with an SCID included in VA administrative databases between October 1, 2005 and October 1, 2015 were identified (N=8838). Cases included 267 men and 59 women with a bisphosphonate prescription propensity matched with up to 4 controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incident lower extremity fractures. RESULTS: There was no significant association between prescriptions for bisphosphonates and incident lower extremity fractures in men (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.62-1.77) or women (OR, 1.02; 95% CI, 0.28-3.75). In men, similar null associations were seen among those who were adherent to bisphosphonate therapy (OR, 1.25; 95% CI, 0.73-2.16), were concomitant users of vitamin D and calcium and a bisphosphonate (OR, 1.05; 95% CI, 0.57-1.96), had more than 1 fracture on different dates during the study period (OR, 0.13; 95% CI, 0.02-1.16) and in those who had undergone DXA testing prior to the date of the bisphosphonate prescription and incident fracture (OR, 1.26; 95% CI, 0.69-2.32). CONCLUSIONS: In men with a traumatic SCI and women with a traumatic SCID, bisphosphonate therapies for osteoporosis do not appear to significantly affect fracture risk. Adequately powered randomized controlled trials are needed to definitively demonstrate efficacy of bisphosphonates for fracture prevention in this population. There is a compelling need to identify new medications to prevent fractures in this high-risk population.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors.

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients' perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10-50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07-2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers' likelihood of exploring context but not contextualizing care. Information about patients' life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Use of PROMIS-29® in US Veterans: Diagnostic Concordance and Domain Comparisons with the General Population.

BACKGROUND: PROMIS® items have not been widely or systematically used within the Veterans Health Administration (VA). OBJECTIVE: To examine the concordance of PROMIS-29® scores and medical record diagnosis in US Veterans and to compare Veteran scores relative to US population norms. DESIGN/PARTICIPANTS: Cross-sectional multi-site survey of Veterans (n = 3221) provided sociodemographic and PROMIS-29® domain data. Electronic medical records provided health condition (depression, anxiety, sleep disorders, pain disorders) diagnosis data. MAIN MEASURES: For each domain, we calculated PROMIS® standardized T scores and used t tests to compare PROMIS® scores for Veterans diagnosed with each targeted health condition vs. those without that documented clinical diagnosis and compare mean Veterans' PROMIS-29® with US adult population norms. KEY RESULTS: Veterans with (vs. without) a depression diagnosis reported significantly higher PROMIS® depression scores (60.3 vs. 49.6, p < .0001); those with an anxiety diagnosis (vs. without) reported higher average PROMIS® anxiety scores (62.7 vs. 50.9, p < .0001). Veterans with (vs. without) a pain disorder reported higher pain interference (65.3 vs. 57.7, p < .0001) and pain intensity (6.4 vs. 4.4, p < .0001). Veterans with (vs. without) a sleep disorder reported higher sleep disturbance (55.8 vs. 51.2, p < .0001) and fatigue (57.5 vs. 51.8, p < .0001) PROMIS® scores. Compared with the general population norms, Veterans scored worse across all PROMIS-29® domains. CONCLUSIONS: We found that PROMIS-29® domains are selectively sensitive to expected differences between clinically-defined groups, suggesting their appropriateness as indicators of condition symptomology among Veterans. Notably, Veterans scored worse across all PROMIS-29(R) domains compared with population norms. Taken collectively, our findings suggest that PROMIS-29® may be a useful tool for VA providers to assess patient's physical and mental health, and because PROMIS® items are normed to the general population, this offers a way to compare the health of Veterans with the adult population at large and identify disparate areas for intervention.

Predicting osteoporosis medication receipt in Veterans with a spinal cord injury: A retrospective cohort study.

Objective: To describe frequency and predictors of use of pharmacological therapies for osteoporosis in persons with a spinal cord injury (SCI).Design: Retrospective cohort study.Setting: United States Veterans Health Administration (VA) national databases.Participants: 11,048 persons with a traumatic SCI who received VA health care between Fiscal Years (FY) 2005-2015. Pharmacy data from VA's Corporate Data Warehouse were used to identify prescriptions for Food and Drug Administration-approved pharmacological treatments for osteoporosis including bisphosphonates, calcitonin, denosumab, raloxifene and teriparatide.Outcome Measures: Demographics, clinical and SCI-related characteristics, receipt of a dual energy x-ray absorptiometry (DXA), and prevalent lower extremity fractures were examined to determine factors related to receiving a pharmacological agent for osteoporosis.Results: 1,041 persons (9.4%) had a prescription for a pharmacological agent for osteoporosis; the majority (n = 964, 93.0%) were bisphosphonates. There was a significant decline in the number of these prescriptions from FY 2005 (13.0%) to FY 2015 (2.2%). In multivariable analysis, age (>50 years) (OR = 1.60, 95% CI 1.31-1.94); female sex (OR = 4.09, 95% CI 2.74-6.09); opioid (OR = 1.24, 95% CI 1.01-1.51) or corticosteroid (OR = 1.92, 95% CI 1.01-1.51) prescriptions; complete injury (OR = 1.26, 95% CI 1.04-1.53); receipt of a DXA scan (OR = 84.03, 95% CI 59.80-118.07) and prevalent fracture (OR = 5.43, 95% CI 4.13-7.15) were positive predictors. Black race (OR = 0.43, 95% CI 0.33-0.57) and obese BMI (OR = 0.59, 95% CI 0.45-0.76) were negative predictors.Conclusions: Prescriptions for osteoporosis medications for persons with a SCI declined in recent years. The strongest predictors for having filled these prescriptions were having had a DXA or a prevalent fracture.

What determines low satisfaction with life in individuals with spinal cord injury?

OBJECTIVE: To examine variables associated with satisfaction with life (SWL) in individuals with a spinal cord injury (SCI). DESIGN: Cross-sectional, national survey to assess SWL, demographic and injury characteristics, health care utilization, chronic conditions (obesity, diabetes, heart problems, lung problems, hypertension, high cholesterol), symptoms (poor sleep, pain, depression), social support, grief/loss, and independence. SETTING/PARTICIPANTS: Community-dwelling Veterans with SCI. Outcome Measures/Analyses: Bivariate analyses were conducted to assess differences in demographics, injury characteristics, chronic conditions, symptoms, social support, grief/loss, and independence in individuals who reported low SWL (≤20) vs. average/high SWL (21-35). Multivariate logistic regression assessed factors independently associated with low SWL. RESULTS: 896 Veterans with SCI (62%) responded. Average age was 62 years, the majority were male (94%), Caucasian (77%), and had paraplegia (61%). Odds of low SWL were 2.4 times greater for individuals experiencing pain (OR = 2.43, CI95: 1.47-4.02, P = 0.0005). Odds of low SWL were increased for individuals reporting greater grief/loss due to their SCI (OR = 1.14, CI95: 1.10-1.18, P < 0.0001). Lesser odds of low SWL were seen for individuals reporting greater emotional social support (OR = 0.97, CI95: 0.96-0.99, P < 0.0001) and independence (OR = 0.94, CI95: 0.90-0.97, P < 0.0001). CONCLUSIONS: Pain and feelings of grief/loss due to injury were associated with low SWL. Self-perceived independence and good social support were associated with better SWL. Along with addressing pain and facilitating independence and social support, these findings suggest that interventions to improve SWL should focus on helping individuals deal with grief/loss due to injury.

Patient perceptions of environmental control units: experiences of Veterans with spinal cord injuries and disorders receiving inpatient VA healthcare.

PURPOSE: To assess patients' perceptions of environmental control units (ECUs) at Veterans Affairs Spinal Cord Injury Centers. MATERIALS AND METHODS: A brief questionnaire was conducted with patients in real-time while they were hospitalised ("on-the-spot questionnaire"); a survey was mailed to patients who had recently been discharged from a hospital stay ("discharge survey"). Data were analysed using descriptive statistics. RESULTS: Seventy on-the-spot questionnaires and 80 discharge surveys were collected. ECU features used most frequently were comparable in responses from both surveys: watching TV/movies (81%, 85%), calling the nurse (68%, 61%), turning lights on/off (63%, 52%), adjusting the bed (53%, 33%), and playing games (39%, 24%). Many on-the-spot questionnaire respondents felt the ECU met their need for independence a great deal (42%). Most respondents to both surveys were satisfied with the ECU (71%, 57%). Areas for improvement included user training, improved functionality of the device and its features, and device design. CONCLUSIONS: ECUs were well-accepted by persons with spinal cord injuries/disorders (SCI/D) in the inpatient setting, and increased patients' perceptions of independence. To maximise usability and satisfaction, facilities should ensure that comprehensive training on ECU use and features available is offered to all patients, and resources are available for timely troubleshooting and maintenance. Implications for rehabilitation An environmental control unit (ECU) is a form of assistive technology that allows individuals with disabilities (such as spinal cord injuries and disorders [SCI/D]) to control functional and entertainment-related aspects of their environment. ECU use can increase functioning, independence and psychosocial well-being among individuals with SCI/D, by allowing users to reclaim control over day-to-day activities that are otherwise limited by their disability. Our study results indicate that, among persons with SCI/D, ECUs are well-accepted and increase perceptions of independence. To maximise usability and patient satisfaction, facilities should ensure that comprehensive training on how to use ECUs and what features are available is offered to all patients, and resources are available for timely troubleshooting and maintenance.

The Relationship Between Pain Interference and Psychosocial Well-Being Among Veterans With Spinal Cord Injuries/Disorders.

OBJECTIVES: The study objectives were to compare psychosocial well-being in individuals with spinal cord injuries/disorders (SCI/D) and above-mean ("high") versus below-mean ("low") pain interference, and to determine whether psychosocial well-being was negatively associated with pain interference. METHODS: Data were collected via a cross-sectional survey mailed in late 2014 to early 2015 to a national sample of veterans with SCI/D who received prior-year Veterans Affairs healthcare and assessed demographics, injury-related factors, select health conditions, pain interference, and psychosocial well-being. Bivariate comparisons and multivariate linear regressions identified factors related to higher pain interference. RESULTS: Approximately 79% of the sample (n = 813) reported high pain interference. Veterans with high (vs. low) pain interference reported worse perceptions of all included psychosocial well-being measures. Regression results indicated that higher pain interference was associated with higher grief/loss (ß = 0.38, P < .0001) and negative psychosocial illness impact (ß = 0.39, P < .0001), and lower positive affect (ß = -0.39, P < .0001), resilience (ß = -0.31, P < .0001), and life satisfaction (ß = -0.39, P < .0001). CONCLUSIONS: The pain experience is independently associated with poor psychosocial well-being among individuals with SCI/D. Efforts to decrease perceptions of pain interference and improve factors associated with psychosocial well-being may symbiotically improve outcomes in SCI/D cohorts. Such efforts may focus on effective pain management programs aligned with patients' treatment preferences.

Examining the relationship between post-traumatic stress disorder and social participation among Veterans with spinal cord injuries and disorders.

PURPOSE: The objectives of this study were to examine differences in social participation among Veterans with spinal cord injuries/disorders with and without post-traumatic stress disorder, and determine if lower social participation was independently associated with having post-traumatic stress disorder. METHODS: A cross-sectional mailed national survey was sent to a national sample of Veterans with spinal cord injuries/disorders who received prior-year Veterans Affairs healthcare. Surveys provided data on: demographics, health conditions, injury characteristics, and social participation. Analyses included bivariate comparisons, and multivariate logistic regression to determine if lower social participation was independently associated with post-traumatic stress disorder. RESULTS: Veterans with (vs. without) post-traumatic stress disorder (n = 896) reported lower social participation (40.2 vs. 43.9, p < 0.0001). Multivariate analyses showed that longer duration of injury (OR = 0.98, 95% CI: 0.97-1.00, p = 0.04) and white race (OR = 0.62, 95% CI: 0.38-1.01, p = 0.05) were associated with lower odds of post-traumatic stress disorder, while a greater number of health conditions (OR = 1.43, 95% CI: 1.25-1.64, p < 0.0001) was associated with greater odds. When controlling for covariates, lower social participation was independently associated with post-traumatic stress disorder (OR = 0.94, 95% CI: 0.90-0.98, p = 0.003). CONCLUSIONS: Results indicate post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. Efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation. Implications for Rehabilitation Individuals with spinal cord injuries/disorders often have post-traumatic stress disorder; in Veterans with spinal cord injuries/disorders this may be compounded by trauma incurred through military experiences. Social participation, an important aspect of rehabilitation and community integration following spinal cord injury or disorder, may be hindered by symptoms of post-traumatic stress disorder. Our data show that post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. These results indicate that efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation in this patient population.

Effect of the environment on participation in spinal cord injuries/disorders: The mediating impact of resilience, grief, and self-efficacy.

OBJECTIVE: The objective of the study was to test the hypothesis that the influence of environmental barriers on participation will be fully mediated by psychosocial factors (resilience, grief or loss, and self-efficacy) among individuals with spinal cord injuries and disorders. METHOD: This was a cross-sectional mailed survey with a national sample of veterans with spinal cord injuries and disorders (n = 565), which included measures of demographics, perceived environmental barriers, participation, resilience, grief or loss, and self-efficacy. Data were analyzed using a latent variable path analysis; the model fit was assessed using χ2, normed χ2, root mean square error of approximation (RMSEA; <0.07), Comparative Fit Index (CFI; ≥0.95), and Tucker-Lewis Index (TLI; ≥0.95). RESULTS: Participants were mostly male (93.9%), Caucasian or White (74.2%), and, on average, 62.4 years of age (SD = 10.48). Almost 62% had paraplegia, and 38.3% had a motor or sensory complete injury. The hypothesized model showed excellent fit, χ2(42) = 153.40, normed χ2 = 3.65, RMSEA = 0.07, CFI = 0.96, TLI = 0.95. To assess for full mediation, a direct path was added from environment to participation. This model showed nearly identical fit, χ2(41) = 153.39, normed χ2 = 3.74, RMSEA = 0.07, CFI = 0.96, TLI = 0.95; the path from environment to participation was not significant, unstandardized coefficient = -0.04, p = .92. Examination of indirect effects of the hypothesized model demonstrated that environment significantly influences participation through psychosocial factors, unstandardized coefficient = -4.85, p < .001. Together these results support full mediation. CONCLUSIONS: In conclusion the present study expands upon past research by suggesting that perceived environmental barriers play a role in internal factors, such as resilience and self-efficacy, which in turn influence participation. Interventions to improve environmental barriers may be warranted, but attention must also be paid to resilience, grief or loss, and self-efficacy to increase participation. (PsycINFO Database Record

Perceptions of Chronic Illness Care Among Veterans With Multiple Chronic Conditions.

OBJECTIVES: Given the burden of multiple chronic conditions (MCCs) in the Veterans Affairs (VA) Health Care System, understanding perspectives of Veterans with MCC is essential to evaluate chronic care and ensure that care and quality improvement efforts align with patient needs. The purpose of this study was to use the Patient Assessment of Chronic Illness Care (PACIC) instrument to examine perceptions of chronic care among Veterans with MCC. METHODS: We conducted a nation-wide, cross-sectional mailed survey. Study inclusion criteria were Veteran patients with MCC who receive care from eight VA facilities. The survey included questions on patient demographics, recent hospital or doctor visits, and the PACIC instrument. Chronic condition and health care utilization data were extracted from VA administrative databases. RESULTS: The sample (n = 3,519) was mostly male; average age was 68.1 years. Mean PACIC summary score was 3.05 (standard deviation [SD] = 1.12). Respondents achieved higher scores (favorable perceptions) in the Delivery System Design and Patient Activation subscales, and lowest scores (unfavorable perceptions) in the Follow-up/Coordination subscale. Characteristics associated with higher scores included non-white race, recent VA doctor visit, and high school or less education. CONCLUSIONS: Perceptions of chronic care were high; however, quality improvements are needed to enhance care continuity and coordination.

Do perceptions of family-centered care differ in older and younger family/caregivers of U.S. veterans?

INTRODUCTION: Family-centered care (FCC) involves partnering with patients and family/caregivers ("caregivers"), engaging them in decisions, and providing support. FCC may be measured across 3 dimensions: respect, collaboration, and support and needs likely vary by caregiver age. The objective was to examine and compare caregiver perceptions of FCC by age. METHOD: We mailed surveys to family/caregivers of Veterans. We collected demographics and measured respect, collaboration, and support using the Family-Centered Care Survey (FCCS). We calculated mean values and conducted bivariate comparisons, dichotomized by caregiver age (≥60 vs. <60), of demographics and FCC constructs. We completed thematic analysis on open-ended text. RESULTS: Caregivers (n = 2,111) aged ≥60 versus <60 were more likely to be spouses (81% vs. 62%, p < .0001) and White (74% vs. 50%, p < .0001). Overall FCC subscales values were high: respect (3.30), collaboration (3.07), and support (2.99). Older caregivers reported higher respect (3.36 vs. 3.22, p < .001), collaboration (3.12 vs. 2.98, p < .0001), and support (3.06 vs. 2.88, p < .0001). Qualitative analysis revealed collaboration, communication, hospital climate, and physical environment as important to FCC and supplemented quantitative findings on age. Examples highlighted both positive perceptions of FCC and areas of concern, such as feeling "unheard" and "like I am bothering providers," and needing "more comfortable seating" and "better parking." DISCUSSION: Caregivers perceived high FCC levels at VA facilities, reporting highest on respect and lowest on support. Older caregivers perceived better FCC compared with younger caregivers. Several concerns identified can be used to target improvements to FCC including: improved support, collaboration between patient/family/provider, and climate/environmental enhancements. (PsycINFO Database Record

Assessing the Associations of Patient-Reported Perceptions of Patient-Centered Care as Supplemental Measures of Health Care Quality in VA.

BACKGROUND: Patient-reported experience measures (PREMs) are useful for assessing health care quality and safety and patients' perceptions of health care. OBJECTIVE: We aimed to assess the relationship between PREMS [e.g., measures of patient-centered care (PCC)] and health care quality metrics. DESIGN: We conducted a national survey via mail. Survey data were supplemented with US Department of Veteran Affairs (VA) administrative data. PARTICIPANTS: Veteran (n = 5512) VA health care users participated in the study. MAIN MEASURES: PCC measures included: patient activation; shared decision-making (SDM); empathy and holistic care; chronic illness care; perceptions of participation, respect for choices, and support; and overall health care experience. Health care quality measures included: preventive care screening receipt; chronic condition management (diabetes, hypertension); and health care utilization (hospitalizations, emergency room (ER) visits). Analyses included: bivariate comparisons of PCC measures by health care quality measures; and multivariate linear regression to identify variables associated with attaining multiple positive health care quality indicators (when controlling for potential confounders). KEY RESULTS: PREMs assessing factors relating to patient-provider communication (e.g., empathic provider care, shared decision-making) are mainly related to clinical indicators representing good chronic condition management, while those relating more broadly to health care in general (e.g., patient activation, chronic illness care) are mainly related to measures of appropriate health care use (e.g., preventive care screening receipt; potentially avoidable hospitalizations; unscheduled care, such as ER visits). When controlling for potential confounders, higher perceptions of the decision-making effectiveness component of SDM (ß = 0.004, p = 0.03) and empathy and holistic care (ß = 0.01, p = 0.02) showed a weak but positive relationship with attaining a greater number of positive health care quality indicators, while a weak but negative relationship emerged for perceptions of participation, respect for choices, and support (ß = -0.003, p = 0.03) and overall VA experiences (ß = -0.10, p = 0.04). CONCLUSIONS: PREMs that measure PCC offer rich data about health care quality while engaging patients, and considering patient experiences and preferences, in performance assessment. PREMs may be used to supplement existing performance metrics.

Patient Perceptions of the Environment of Care in Which Their Healthcare is Delivered.

OBJECTIVE: To measure patients' perceptions of the environment of care (EOC), with a focus on the physical environment, in which healthcare is delivered. BACKGROUND: The EOC may impact patient experiences, care perceptions, and health outcomes. EOC may be improved through redesign of existing physical structures or spaces or by adding nurturing amenities. METHODS: Demographics, health status, hospital use, and data on the environment (physical, comfort, orientation, and privacy) were collected via a mailed cross-sectional survey sent to patients seen at four hospital Centers of Innovation (COIs; that implemented many modifications to the healthcare environment to address physical, comfort, orientation, and privacy factors) and four matched controls, supplemented with checklist and VA administrative data. A modified Perceived Hospital Environment Quality Indicators instrument was used to measure patients' EOC perceptions. RESULTS: Respondents (3,321/5,117; 65% response) rated, [mean (SD)], exterior space highest, 3.09 (0.73), followed by interior space, 2.96 (0.74), and privacy, 2.44 (1.01). COIs had significantly higher ratings than controls on interior space (2.99 vs. 2.96, p = .02) and privacy (2.48 vs. 2.38, p = .005) but no differences for exterior space. Subscales with significantly higher ratings in COIs (vs. controls) in interior space were "spatial-physical comfort" and "orientation," for example, clean, good signage, spacious rooms, and for privacy included "not too crowded" and "able to talk without being overheard." Checklist findings confirmed the presence of EOC innovations rated highly by patients. CONCLUSIONS: Patients identified cleanliness, good signs/information points, adequate seating, nonovercrowding, and privacy for conversations as important. Hospital design modifications, with particular attention to the physical environment, can improve patient EOC perceptions.

Factors Influencing Self-Care Behaviors in Persons with Spinal Cord Injuries and Disorders.

Background: Individuals with spinal cord injury/disorder (SCI/D) must learn to adjust to and manage functional challenges after SCI/D onset. For these individuals, resilience (ie, the adaptive response to stressful events) may be related to their willingness and ability to conduct self-care behaviors. Objective: The study objectives were to examine the relationship between patient-reported perceptions of independence in performing self-care behaviors and resilience among Veterans with SCI/D and to examine variables (including resilience) associated with high self-care scores (controlling for confounders). Methods: In this cross-sectional survey, we conducted bivariate analyses to examine differences in demographic, injury, and health characteristics and resilience scores for individuals with SCI/D. We conducted a multivariate block-design linear regression to examine factors associated with ability to perform self-care. Results: Level of injury (ß = 7.74, P < .0001), resilience (ß = 0.08, P = .0216), marital status (ß = 1.75, P = .0445), and living arrangement (ß = 4.37, P < .0001) were positively related to higher self-care behaviors. Completeness of injury (ß = -2.79, P < .0001), age (ß = -0.09, P = .0052), age at injury (ß = -0.05, P = .0129), and number of comorbid health conditions (ß = -0.72, P < .0001) showed negative relationships with higher self-care. Conclusions: Self-care ability is related to multiple factors, including resilience. The positive relationship between resilience and self-care suggests that greater resilience, independent of injury level/severity, may contribute to improved self-care behaviors in individuals with SCI/D. Other factors that showed a positive relationship with self-care included younger age, living alone, paraplegic level injury, and fewer health conditions. Understanding the profile of persons with SCI/D with regard to self-care behaviors is important to the development of tailored interventions to improve self-care.

Attitudes toward influenza vaccination improvement strategies in Veterans Affairs health care workers providing care for patients with spinal cord injuries and disorders: Acceptability of a declination form program.

BACKGROUND: Influenza is associated with high rates of morbidity and mortality. The most effective way to prevent influenza or severe consequences from the illness is vaccination, and key organizations recommend that all health care workers (HCWs) be vaccinated annually for influenza. Recent literature suggests declination form programs (DFPs) are a useful approach to improve HCW influenza vaccination rates. OBJECTIVE: To understand support for and beliefs about use of an influenza vaccination DFP, and how this is associated with HCW beliefs about other influenza vaccination improvement strategies. METHODS: Data were collected via a cross-sectional mailed national survey. Participants included HCWs providing care to Veterans with spinal cord injuries and disorders (SCI/D) from 23 nationwide Veterans Affairs facilities. Analyses included bivariate analyses of outcomes among DFP supporters vs. non-supporters. RESULTS: Of the HCW respondents, 67% reported that they would support a DFP at their facility. A greater proportion of HCWs who support (vs. do not support) DFPs reported receiving an annual influenza vaccination (86.35% vs. 65.81%, p<0.0001). Similarly, a significantly greater proportion of HCWs who support DFPs (vs. do not support) reported willingness to receive an influenza vaccination (83.79% vs. 61.48%, p<0.0001) and nasal spray influenza vaccination (45.75% vs. 32.50%, p=0.0156). HCWs who support DFPs were more likely to report a great deal of influence in almost all typical vaccination improvement campaign strategies on their decision to be vaccinated, and less likely to endorse commonly provided reasons for refusing vaccination as valid. CONCLUSION: More HCWs who support DFPs engage in important influenza-related health behaviors (e.g., vaccination), and support other influenza vaccination improvement strategies. Facilities may benefit from implementing DFPs as part of their vaccination improvement campaign. Support for DFPs among HCWs is high, suggesting implementing this as a policy would be well-received by staff, and potentially effective in increasing HCW influenza vaccination.

Factors related to caregiving for individuals with spinal cord injury compared to caregiving for individuals with other neurologic conditions.

CONTEXT/OBJECTIVE: To compare outcomes among caregivers of adults with spinal cord injuries (SCIs) to caregivers of adults with other neurological conditions, and determine if caregiving for SCI is associated with poor health status and chronic conditions. DESIGN: Secondary data analysis of 2009/2010 Behavioral Risk Factor Surveillance System survey. PARTICIPANTS: Informal caregivers of adults with neurological conditions. OUTCOME MEASURES: Sociodemographics, caregiving factors (e.g. role, emotional support, life satisfaction), lifestyle behaviors, chronic conditions, and health status. RESULTS: Demographics and lifestyle behaviors did not differ in caregivers of adults with SCI vs. caregivers of adults with other neurological conditions (except younger age of SCI caregivers). Greater proportions of caregivers of adults with SCI had coronary heart disease (CHD) (12% vs. 6%, P = 0.06) and were obese (43% vs. 28%, P = 0.03). Frequent physical distress was reported by 20% of caregivers of persons with SCI (vs. 12% of other caregivers, P = 0.09), but mental health did not differ between caregiver groups. A greater proportion of caregivers of adults with SCI experienced insufficient sleep (47% vs. 30%, P = 0.008) and more days without enough sleep (13 vs. 9 days, P = 0.008). Odds of being younger, caregiver of a spouse, having CHD, and being obese were associated with being a caregiver of an adult with SCI. CONCLUSION: Caregivers of adults with SCI report similar mental health status, but more poor sleep, and have increased odds of CHD and obesity. Interventions to address physical distress, improve sleep, and address CHD and obesity are needed in this cohort.