Sherri L. LaVela

Diabetes mellitus in individuals with spinal cord injury or disorder

Abstract Background/Objective: To examine diabetes prevalence, care, complications, and characteristics of veterans with a spinal cord injury or disorder (SCI/D). Methods: A national survey of veterans with an SCI/D was conducted using Behavioral Risk Factor Surveillance System (BRFSS) survey questions. Data were compared with national Centers for Disease Control and Prevention BRFSS data for veteran and nonveteran general populations. Results: Overall prevalence of diabetes in individuals with an SCI/D was 20% (3 times higher than in the general population). Veterans with an SCI/D and veterans, in general, had a higher prevalence of diabetes across all age groups; however, those with an SCI/D who were 45 to 59 years of age had a higher prevalence than other veterans. One fourth of the persons with an SCI/D and diabetes reported that diabetes affected their eyes or that they had retinopathy (25%), and 41 % had foot sores that took more than 4 weeks to heal. More veterans, both with (63%) and without an SCI/D (60%), took a class on how to manage their diabetes than the general population (50%). Veterans with an SCI/D and diabetes were more likely to report other chronic conditions and poorer quality of life than those without diabetes. Conclusions: Diabetes prevalence is greater among veterans with an SCI/D compared with the civilian population, but is similar to that of other veterans, although it may occur at a younger age in those with an SCI/D. Veterans with an SCI/D and diabetes reported more comorbidities, more slow-healing foot sores, and poorer quality of life than those without diabetes. Efforts to prevent diabetes and to provide early intervention in persons with SCI/D are needed.

Psychological health in older adult spousal caregivers of older adults

Objectives: The need for informal caregiving has been rapidly increasing across several countries. Spouses comprise a sizeable segment of informal caregivers and typically represent an older cohort with special health concerns. The objective of this review was to examine psychological health outcomes in older adult spouses caring for older adults. Methods: Literature review/synthesis (1999—2009). Results: Compared to demographically matched married non-caregiving controls, older adult spousal caregivers experienced more cognitive functioning difficulties, strain, distress, stress, loneliness, depression, anxiety and poorer mental health. Caregivers of spouses with cognitive impairments, quite often wives, were especially affected by poor psychological health, as were caregivers who were new to the caregiving role and those who rated caregiving as stressful. Psychological health improved when the caregiving role ceased. Discussion: Several poor psychological outcomes were found in older adults caring for their spouses; the magnitude of which varied and were more pronounced under certain circumstances. To preserve caregiver health, maintain recipient health and care quality and avoid exceeding system of care capacity, efforts are needed to provide support to older adult spousal caregivers and recipients. Couples may need to be assessed as a unit, taking gender and cultural considerations into account, and additional resources may be required.

Epidemiology of hospital-acquired infections in veterans with spinal cord injury and disorder.

OBJECTIVE To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D). DESIGN Retrospective medical record review. SETTING Midwestern Department of Veterans Affairs spinal cord injury center. PARTICIPANTS A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003). RESULTS A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariable regression demonstrated that predictors of HAI were longer length of hospital stay (P=.002), community-acquired infection (P=.007), and use of a urinary invasive device (P=.01) or respiratory invasive device (P=.04). CONCLUSIONS The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.

Factors predicting pressure ulcers in veterans with spinal cord injuries.

Smith BM, Guihan M, LaVela SL, Garber SL: Factors predicting pressure ulcers in veterans with spinal cord injuries. Am J Phys Med Rehabil 2008;87:750–757. Objectives:To identify patient risk factors for pressure ulcers in a sample of veterans with spinal cord injuries and disorders. Design:A survey incorporating questions from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System was mailed to individuals with spinal cord injuries and disorders in 2003. A multiple logistic regression model including 2574 respondents was used to examine the association between patient characteristics and the self-report of pressure ulcers. Results:Approximately 36% of respondents reported having pressure ulcers during the previous year. Respondent characteristics significantly associated with report of one or more pressure ulcers included diabetes (incidence rate ratio [IRR] = 1.36, P < 0.001), smoking (IRR = 1.16, P = 0.030), injury duration >30 yrs (IRR = 1.27, P = 0.000), and reporting frequent depressive symptoms (IRR = 1.30, P < 0.001). Veterans who did not have injuries related to their military service (IRR = 1.39, P < 0.001) or who received care at non-VA facilities in addition to or instead of VA facilities (IRR = 1.13, P = 0.024) were more likely than other veterans to report pressure ulcers. Conclusion:Efforts to prevent pressure ulcers should include increased attention to managing diabetes and depressive symptoms. Further research to explore the association between multiple healthcare system use and the risk of pressure ulcers should be pursued.

Males Aging With a Spinal Cord Injury: Prevalence of Cardiovascular and Metabolic Conditions

OBJECTIVE To compare the prevalence of cardiovascular and metabolic conditions in male veterans aging with spinal cord injury (SCI) with that of older men comparison groups. DESIGN Cross-sectional survey. SETTING National community dwelling. PARTICIPANTS Men 65 years and older (veterans with SCI [n=794] injured at least 20y, veterans [n=13,528], and general population [n=6105]). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence of diabetes, myocardial infarction (MI), stroke, and coronary heart disease (CHD). RESULTS In older adult men with SCI, prevalences of diabetes, MI, stroke, and CHD were 20.30%, 18.70%, 9.84%, and 15.47%, respectively. The odds for stroke were 1.4 times higher in veterans with SCI than general veterans (P<.05), and there was a trend to higher odds for stroke in men with SCI than in the general population (P=.06). The odds for CHD were significantly lower for veterans with SCI than both comparison groups. Being a past smoker was associated with greater odds for diabetes, MI, and CHD, and being a current smoker was associated with higher odds for stroke. High blood pressure and high cholesterol levels were associated with higher odds for all conditions examined. CONCLUSIONS Diabetes and MI were most prevalent in older adults, but the presence was similar in men with SCI (vs other men). In older adult men, SCI appeared to be protective of CHD. Stroke was most prevalent in veterans with SCI, and controlling for demographic and risk factors, SCI was associated independently with stroke. These findings may be useful for prioritizing preventive health strategies and planning long-term care for men aging with SCI.

Using VA data for research in persons with spinal cord injuries and disorders: lessons from SCI QUERI.

The Department of Veterans Affairs (VA) provides integrated services to more than 25,000 veterans with spinal cord injuries and disorders (SCI/D). VA data offer great potential for providing insights into healthcare utilization and morbidity, and these capabilities are central to efforts to improve healthcare for veterans with SCI/D. The objective of this article is to introduce researchers to the use of VA data to examine questions related to SCI/D using examples from Spinal Cord Injury (SCI) Quality Enhancement Research Initiative studies. Sources of VA data available to investigators interested in SCI/D-related research include national-level VA administrative and clinical databases and primary data (medical record review, patient surveys). Methods used to identify veterans with SCI/D include the Allocation Resource Center cohort, the Spinal Cord Dysfunction (SCD) Registry, and the VA inpatient SCI flag; only 33% of veterans were included in all three groups (n = 12,306). While neurological level of SCI was unknown for approximately a third of veterans (from SCD Registry data alone), the percent decreased to 13% when augmented with diagnostic codes. Primary data can be used to augment other missing SCI data and to provide more detailed information about complications commonly associated with SCI/D.

Influenza Vaccination Among Veterans With Spinal Cord Injury: Part 2. Increasing Vaccination Rates

Abstract Background/Objective: Respiratory complications are the leading cause of morbidity and mortality among individuals with spinal cord injury (SCI). Influenza vaccination is effective in reducing the likelihood of contracting influenza and of subsequent respiratory complications, hospitalizations, and deaths. Historically, vaccination rates for veterans with SCI treated in Veterans Affairs (VA) facilities have been low. The objective of this study was to increase vaccination rates in this population using a multi pronged strategy. Methods: A quasi-experimental design involving 2,2 84 veterans treated at 8 VA SCI Centers was used. Patients at 4 centers received reminder letters and educational materials tailored to SCI. Provider education included mailed reminders and posters in SCI clinical areas. Clinical champions were identified at each site. Four other centers, matched to the study sites in program size and prior vaccination rates, served as comparison sites providing usual care. Vaccination rates were assessed using mailed surveys with telephone follow-up. Results: The influenza vaccination rate was significantly higher in the intervention group than in the comparison group (60.5% vs 54.3%; P = 0.01). Vaccine recipients were older than nonrecipients (mean age 60.8 vs 53.1 years; P < 0.0001). Reasons for not receiving a vaccination included refusal, feeling that being vaccinated was not worth the trouble, and not believing that the vaccine would prevent influenza. Conclusions: Use of low-cost mailed reminders and educational materials resulted in significantly higher vaccination rates. Further efforts to reach targeted subgroups of nonrecipients, such as patients who are younger or from an ethnic minority, are warranted.

Interventions to Increase Influenza Vaccination Rates in Veterans With Spinal Cord Injuries and Disorders

Abstract Objective: To increase the percentage of veterans with spinal cord injuries and disorders (SCI&D) who receive annual influenza vaccinations. Design: A repeated measures quality improvement project using several integrated evidence-based interventions. Setting: 23 Veterans Affairs (VA) SCI Centers. Patients: Veterans with SCI&D average age = 57.3 years (range 21-102 y). Interventions: Patient reminder letters and education; provider reminders and posters; computerized clinical reminders for vaccination targeted to SCI&D; standing orders. Main outcome measures: Patient selfreported vaccination status. Results: Baseline vaccination rate was 33% in fiscal year (FY) 2001. The percentage of veterans with SCI&D who reported receiving vaccinations increased from 62.5% in year 1 (FY2002) to 67.4% in FY2003 (P =0.004); for individuals younger than 50 years of age, rates increased from 50% to 54%. Predictors of vaccination were age 65 years of age or older, VA health care visit in past year, nonsmoker, believing vaccination is important, having a health condition that may contribute to respiratory complications, and self-reported influenza in prior year. Conclusions: Vaccination rates were higher than baseline and higher than reported for other high-risk groups. Interventions that incorporate system-wide approaches plus patient and provider education and reminders were moderately effective in increasing vaccination rates. Targeting younger persons, smokers, and those who do not use VA care may further improve rates.

Health-related quality of life for veterans with spinal cord injury.

Study design:Cross-sectional.Objectives:The objective of this study was to examine the association between the characteristics of individuals with spinal cord injury (SCI) and self-reported health-related quality of life (HRQoL).Setting:The United States.Methods:Questions from the Behavioral Risk Factor Surveillance System (BRFSS) survey were sent to veterans with SCI. The analyses included 2302 respondents. Logistic regression analysis was used to examine the association between subject characteristics and the following four measures of HRQoL: frequent physical distress (FPD), frequent mental distress (FMD), frequent depressive symptoms (FDS) and poor or fair self-reported health.Results:Approximately 19% of the respondents reported FMD, 27% reported FPD, 17% reported FDS and 29% reported poor or fair health. Veterans who self-reported chronic illnesses, had higher odds of reporting FPD, FMD, FDS and poor or fair health than veterans who did not report chronic illnesses. Smoking was significantly associated with decreased HRQoL. Older veterans had higher odds of reporting poor or fair health and FPD than younger veterans. Higher levels of education were associated with lower odds of FMD, FDS and poor or fair health.Conclusions:Chronic illnesses and smoking have a substantial effect on HRQoL for persons with SCI, suggesting the importance of continued efforts to improve smoking cessation methods and to treat and prevent chronic conditions.

Optimizing Primary Care Telephone Access and Patient Satisfaction

Telephone medicine is often preferred by patients to meet primary care needs and may be associated with high patient satisfaction. This article presents findings about incoming patient calls to primary care for medically based reasons during office hours and reports factors independently associated with telephone encounter satisfaction, considering patient characteristics, call reasons, and staff responsiveness, for a national cohort of primary care users. Interviews were conducted with patients from 18 nationwide primary care clinics during the fall of 2009. Calling for an urgent medical issue was associated with dissatisfaction. Odds of call satisfaction were greater when patients thought staff was friendly (10x), call answer was timely (5x), and needed medical information was provided (7x). These findings can be used for interventions to optimize telephone access and patient satisfaction which is beneficial because satisfactory telephone encounters reduce primary care use and satisfied patients are more likely to be engaged in their health care.