RESUMEN
BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.
Asunto(s)
Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/prevención & control , Infección Hospitalaria/prevención & control , Unidades de Cuidados Intensivos , Adulto , Cateterismo Venoso Central/efectos adversos , Infección Hospitalaria/epidemiología , Humanos , Incidencia , Control de Infecciones/métodos , Evaluación de Programas y Proyectos de Salud , Estados Unidos/epidemiologíaRESUMEN
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.
Asunto(s)
Accesibilidad a los Servicios de Salud/normas , Hospitales de Veteranos/normas , Medicare Part D/normas , Sistemas de Medicación en Hospital/normas , Relaciones Profesional-Paciente , Veteranos , Anciano , Anciano de 80 o más Años , Comunicación , Atención a la Salud/métodos , Atención a la Salud/normas , Femenino , Humanos , Masculino , Estados UnidosRESUMEN
OBJECTIVE: To describe the early results of the U.S. Department of Veterans Affairs (VA) screening program for traumatic brain injury (TBI) and to identify patient and facility characteristics associated with receiving a TBI screen and results of the screening. DESIGN: National retrospective cohort study. SETTING: VA Medical facilities. PATIENTS: A total of 170,681 Operation Enduring Freedom and/or Operation Iraqi Freedom (OEF/OIF) Veterans who sought care at VA medical facilities from April 2007 to September 30, 2008. METHODS: Data were abstracted from VA administrative and operational databases, including patient demographics, facility characteristics, and outcomes. MAIN OUTCOME MEASUREMENTS: The main outcomes were receipt of and results of the TBI screen. RESULTS: The majority of veterans eligible received the TBI screen (91.6%). Screening rates varied by patient and facility characteristics. In all, 25% of screened veterans had probable TBI exposure, in which the majority of the exposures were blasts (85.0%). The rate of a positive TBI screen was 20.5% for the screened cohort. Male gender, service in the army, multiple deployments, and mental health diagnoses in the previous year were associated with a positive screen. CONCLUSIONS: TBI screening rates are high in VA; concomitant mental health diagnoses were highly prevalent in individuals with positive TBI screens. These data indicate that there will be a significant need for long-term health care services for veterans with TBI symptomatology.
Asunto(s)
Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/epidemiología , Tamizaje Masivo/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Adulto , Campaña Afgana 2001- , Población Negra/estadística & datos numéricos , Traumatismos por Explosión/epidemiología , Estudios de Cohortes , Depresión/epidemiología , Cefalea/epidemiología , Hospitales de Veteranos , Humanos , Guerra de Irak 2003-2011 , Genio Irritable , Modelos Logísticos , Masculino , Estado Civil/estadística & datos numéricos , Estudios Retrospectivos , Factores Sexuales , Trastornos del Sueño-Vigilia/epidemiología , Trastornos por Estrés Postraumático/epidemiología , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosRESUMEN
Approximately 15% of casualties in the Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) conflicts received mild traumatic brain injury (TBI). To identify Veterans who may benefit from treatment, the Department of Veterans Affairs (VA) implemented a national clinical reminder in 2007 to screen for TBI. Veterans who screen positive are referred for a comprehensive TBI evaluation. We conducted a national retrospective study of OIF/OEF Veterans receiving care at VA facilities between 2007 and 2008. We examined the association of the TBI screen with healthcare costs over a 12 mo period following the initial evaluation. Of the Veterans, 164,438 met inclusion criteria: 31,627 screened positive, 118,545 screened negative, and 14,266 received no TBI screening. Total healthcare costs of Veterans who screened positive, screened negative, or had no TBI screening were $9,610, $5,184, and $3,399, respectively (p < 0.001). Understanding these healthcare utilization and cost patterns will assist policymakers to address the ongoing and future healthcare needs of these returning Veterans.
Asunto(s)
Lesiones Encefálicas/diagnóstico , Lesiones Encefálicas/terapia , Costos de la Atención en Salud/estadística & datos numéricos , Servicios de Salud/economía , Servicios de Salud/estadística & datos numéricos , Traumatismo Múltiple/terapia , Veteranos/estadística & datos numéricos , Adulto , Campaña Afgana 2001- , Atención Ambulatoria/economía , Atención Ambulatoria/estadística & datos numéricos , Lesiones Encefálicas/rehabilitación , Femenino , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Hospitalización/economía , Humanos , Guerra de Irak 2003-2011 , Masculino , Trastornos Mentales/etiología , Trastornos Mentales/terapia , Servicios de Salud Mental/economía , Servicios de Salud Mental/estadística & datos numéricos , Traumatismo Múltiple/rehabilitación , Atención Primaria de Salud/economía , Atención Primaria de Salud/estadística & datos numéricos , Rehabilitación/economía , Estudios Retrospectivos , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) and spinal cord injury and disorders (SCI/D) are common and costly conditions among Veterans. However, little is known about CKD among adults with SCI/D. METHODS: We conducted cross-sectional analyses of Veterans with SCI/D across all VA facilities in 2006. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) and categorized by standard eGFR strata. eGFR was calculated in two ways: (a) the Modification of Diet in Renal Disease (MDRD) equation and (b) the MDRD equation + an empirically derived correction factor for SCI/D (MDRD-SCI/D). Logistic regression models were used to examine the relationship between patient characteristics and CKD. RESULTS: Among 9,333 SCI/D Veterans with an available eGFR, the proportion with CKD was substantially higher based on the MDRD-SCI/D equation (35.2%) than based on the MDRD equation (10.2%). In adjusted analyses, while older age (OR for >65 years = 2.53; 95% CI: 2.21-2.89), female sex (OR 2.18; 95% CI: 1.62-2.92), and a non-traumatic cause for injury (OR 1.39; 95% CI: 1.23-1.57) were associated with an increased odds of CKD, black race (OR 0.64; 95% CI: 0.56-0.72) and a duration of injury of ≥10 years (OR 0.76; 95% CI: 0.67-0.86) were associated with a decreased odds of CKD. Diagnostic codes for CKD and nephrology visits were infrequent for SCI/D Veterans with CKD (27.51 and 6.58%, respectively). CONCLUSION: Using a recently validated version of the MDRD equation with a correction factor for SCI/D, over 1 in 3 Veterans with SCI/D had CKD, which is more than 3-fold higher than when traditional MDRD estimation is used.
Asunto(s)
Insuficiencia Renal Crónica/epidemiología , Enfermedades de la Médula Espinal/complicaciones , Enfermedades de la Médula Espinal/epidemiología , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/epidemiología , Adulto , Factores de Edad , Anciano , Intervalos de Confianza , Estudios Transversales , Femenino , Tasa de Filtración Glomerular , Humanos , Modelos Logísticos , Masculino , Conceptos Matemáticos , Persona de Mediana Edad , Oportunidad Relativa , Prevalencia , Insuficiencia Renal Crónica/etnología , Insuficiencia Renal Crónica/etiología , Factores Sexuales , Estados Unidos/epidemiologíaRESUMEN
We examined the prevalence, severity, etiology, and treatment of audiology problems among Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans with mild traumatic brain injury (TBI). A retrospective chart review was performed of 250 Veterans with mild TBI. Results of a comprehensive second-level mild TBI evaluation and subsequent visits to audiology were evaluated. We found the vast majority (87%) of Veterans reported some level of hearing disturbance and those involved in blast injuries reported a higher incidence of hearing disturbance than those with other injury etiologies. Audiology referrals were given to 75 Veterans and 37 attended. At this visit, Veterans reported tinnitus (75.7%) and hearing loss (59.8%). Nearly half (48.6%) of Veterans were diagnosed with conductive hearing loss, sensorineural hearing loss, or central auditory dysfunction. An additional 24.3% of Veterans had subclinical levels of auditory dysfunction. Our study has highlighted the increased prevalence of hearing loss among OIF/OEF Veterans and, thus, the need for appropriate referrals and treatment. Strategies to address perceived stigma associated with hearing loss may increase attendance at follow-up visits. Additionally, while only a third of audiograms were found to be abnormal, advanced testing resulted in a significant percentage of our population being diagnosed with auditory dysfunction.
Asunto(s)
Lesiones Encefálicas/complicaciones , Pérdida Auditiva/etiología , Veteranos/estadística & datos numéricos , Adulto , Campaña Afgana 2001- , Audiometría , Traumatismos por Explosión/complicaciones , Traumatismos por Explosión/epidemiología , Lesiones Encefálicas/epidemiología , Femenino , Pérdida Auditiva/epidemiología , Pruebas Auditivas , Humanos , Guerra de Irak 2003-2011 , Masculino , Prevalencia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores Socioeconómicos , Acúfeno/epidemiología , Acúfeno/etiología , Estados Unidos/epidemiología , Veteranos/psicología , Adulto JovenRESUMEN
OBJECTIVES: To report the prevalence and characteristics of headaches in veterans with mild traumatic brain injury (TBI) and to describe most common treatment strategies after neurological evaluation. METHODS: We conducted a retrospective cohort study. The setting was a United States Veterans Healthcare Administration Polytrauma Network Site. The study participants consisted of 246 veterans with confirmed diagnosis of mild TBI. The main outcome measures were: Self-reported head pain occurring 30 days prior to initial mild TBI screening; headache severity measured by the Neurobehavioral Symptom Inventory; headache characteristics; and treatment prescribed by neurologists. RESULTS: The majority (74%) of veterans with a confirmed diagnosis of mild TBI (N=246), due largely to blast exposure, reported headaches in the 30 days preceding the initial mild TBI evaluation. Thirty-three percent of these veterans (N=81) were referred to neurology for persistent headaches. Of the 56 veterans attending the neurology evaluation, 45% were diagnosed with migraine headaches and 20% with chronic daily headaches. The most commonly used abortive agents were triptans (68%) and the most common preventive medications were anticonvulsants (55%) and tricyclics (40%). CONCLUSION: There was an increased prevalence of headaches in veterans with mild TBI. Most of the TBI veterans in our study group were exposed to blast injury and findings indicate that the nature of head trauma may be contributing to headaches. Findings highlight the need for developing effective headache prevention and treatment strategies for all persons with mild TBI and in particular for veterans with blast-related mild TBI.