Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience

A survey of knowledge, experiences, and quality of life impacts related to urinary tract infections among people with neurogenic bladder

BACKGROUND

Urinary tract infections (UTI) are common complications in people with neurogenic bladder (NB). Limited data exist on UTI-related knowledge, experiences, and quality of life (QoL) impacts in this population.

METHODS

We mailed surveys to 289 Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis, or Parkinson's Disease who had a UTI diagnosis at four Veterans Affairs Medical Centers between May 2022-May 2023. The survey was adapted from existing instruments and previously collected qualitative data and assessed patient knowledge and experiences with UTI and QoL impacts. Descriptive statistics summarized responses and scaled QoL scores were calculated, with higher scores indicating greater negative impact.

RESULTS

Most respondents (n = 71) were older (mean age = 69), had SCI/D (77%), and used urinary catheters (77%). Over a third had misperceptions about antibiotic risks and the significance of a positive urine culture or bacteriuria for diagnosing UTI. 18% wanted more information about UTIs, with most preferring written materials (77%) or information at healthcare provider visits (62%). The strongest QoL impacts were on daily activities, with many respondents indicating UTIs affect diet (50%), travel (53%), and sex life (60%). Mean [standard deviation (SD)] scaled QoL score was 40.8 (15.3) out of a maximum of 75, with ≥ 3 UTIs in the prior year associated with higher scores (p = 0.02).

CONCLUSIONS

People with NB may have misperceptions about UTI diagnosis and antibiotic risks, and experience substantial QoL impacts from UTIs. Provider encounters for suspected UTI may be good opportunities for delivering written education and assessing QoL impacts.

Evolution of the Veterans Health Administration Spinal Cord Injuries and Disorders (SCI/D) Registry (VHA SCIDR): Characterization from 1994 to 2022

CONTEXT

Veterans Health Administration (VHA) maintained a registry of identified and verified cases of US Veterans with spinal cord injuries and disorders (SCI/D) since 1994: VHA SCI/D Registry (VHA SCIDR). Data elements, capture, and storage methods varied over time.

OBJECTIVE

Describe the consolidation and harmonization of historical VHA SCIDR data spanning three decades during its evolution to an automated platform and report population characteristics.

METHODS

The VHA SCIDR captured data using four distinct acquisition methods over 28 years, including cases of Veterans with SCI/D receiving SCI/D System of Care services, via 25 SCI/D Centers and 122 Spoke Sites throughout the VHA healthcare system. Foundational elements of VHA SCIDR data capture methods, harmonization of data elements with the current automated algorithm, access protocol, and governance structure are described.

RESULTS

From Fiscal Years (FYs) 1994 to 2022, VHA SCIDR identified 52,407 Veterans with traumatic or non-traumatic SCI/D, and 96.95% were male, 56.09% White, 16.57% were Black, 1.23% Asian and Pacific Islander, 0.75% Native American, and 25.36% unknown. Traumatic etiology comprised 53.39% of the sample, while 31.75% were non-traumatic, with 14.87% missing etiology classification. Injury category proportions were 5.19% high tetraplegia, 5.83% low tetraplegia, 5.85% high paraplegia, 7.53% low paraplegia, and 23.35% AIS D, with 52.25% missing or unable to be calculated.

CONCLUSIONS

VHA SCIDR is one of the three largest SCI/D registries in North America and is the case-identification platform for VHA SCI/D operations, program evaluation, and research studies. VHA SCIDR is connected to each Veteran's VHA healthcare data, facilitating big data research.

Exoskeletal-Assisted Walking in Veterans With Paralysis: A Randomized Clinical Trial

Importance

Robotic exoskeletons leverage technology that assists people with spinal cord injury (SCI) to walk. The efficacy of home and community exoskeletal use has not been studied in a randomized clinical trial (RCT).

Objective

To examine whether use of a wheelchair plus an exoskeleton compared with use of only a wheelchair led to clinically meaningful net improvements in patient-reported outcomes for mental and physical health.

Design, Setting, and Participants

This RCT of veterans with SCI was conducted at 15 Veterans Affairs medical centers in the US from September 6, 2016, to September 27, 2021. Data analysis was performed from March 10, 2022, to June 20, 2024.

Interventions

Participants were randomized (1:1) to standard of care (SOC) wheelchair use or SOC plus at-will use of a US Food and Drug Administration (FDA)-cleared exoskeletal-assisted walking (EAW) device for 4 months in the home and community.

Main Outcomes and Measures

Two primary outcomes were studied: 4.0-point or greater improvement in the mental component summary score on the Veterans RAND 36-Item Health Survey (MCS/VR-36) and 10% improvement in the total T score of the Spinal Cord Injury-Quality of Life (SCI-QOL) physical and medical health domain and reported as the proportion who achieved clinically meaningful changes. The primary outcomes were measured at baseline, post randomization after advanced EAW training sessions, and at 2 months and 4 months (primary end point) in the intervention period. Device usage, reasons for not using, and adverse events were collected.

Results

A total of 161 veterans with SCI were randomized to the EAW (n = 78) or SOC (n = 83) group; 151 (94%) were male, the median age was 47 (IQR, 35-56) years, and median time since SCI was 7.3 (IQR, 0.5 to 46.5) years. The difference in proportion of successes between the EAW and SOC groups on the MCS/VR-36 (12 of 78 [15.4%] vs 14 of 83 [16.9%]; relative risk, 0.91; 95% CI, 0.45-1.85) and SCI-QOL physical and medical health domain (10 of 78 [12.8%] vs 11 of 83 [13.3%]; relative risk, 0.97; 95% CI, 0.44-2.15) was not statistically different. Device use was lower than expected (mean [SD] distance, 1.53 [0.02] miles per month), primarily due to the FDA-mandated companion being unavailable 43.9% of the time (177 of 403 instances). Two EAW-related foot fractures and 9 unrelated fractures (mostly during wheelchair transfers) were reported.

Conclusions and Relevance

In this RCT of veterans with SCI, the lack of improved outcomes with EAW device use may have been related to the relatively low device usage. Solutions for companion requirements and user-friendly technological adaptations should be considered for improved personal use of these devices.

Trial Registration

ClinicalTrials.gov Identifier: NCT02658656.

Chronic opioid prescription in veterans with spinal cord injury: Prevalence and associated factors

OBJECTIVE

Chronic opioid use presents long-term health risks for individuals with spinal cord injury (SCI). The purpose of the study was to characterize patterns and correlates of the chronic prescription of opioids among individuals with SCI in a population of Veterans receiving care though the Veteran's Health Administration.

DESIGN

A retrospective, longitudinal cohort study examined the US Department of Veterans Affairs electronic medical record data of veterans with SCI. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable models examined associations with demographics and pre-existing medical comorbidities.

SETTING

US Department of Veterans Affairs, Veteran's Health Administration.

PARTICIPANTS

National sample of Veterans with SCI (N = 10,811).

MAIN OUTCOME MEASURE

Chronic prescription opioid use (≥90 days).

RESULTS

All types of prescription opioid use declined across the three study years (chronic opioid use prevalence = 33.2%, 31.7%, and 29.7%, respectively). Past history of depression, COPD, diabetes, pain condition, opioid use and tobacco use disorders were associated with a greater likelihood of current chronic prescription opioid use. Non-white race, hyperlipidemia, dementia, and tetraplegia were associated with a lower likelihood of current chronic prescription opioid use. When added to the multivariable model, prior chronic opioid prescription use was robustly associated with current chronic prescription opioid use, but most other factors were no longer significantly associated with current opioid use.

CONCLUSIONS

This study demonstrates opioid reduction over time from 2015 to 2017, however, chronic prescription opioid use remains common among a substantial minority of Veterans with SCI. Several demographics and comorbidities may provide clinicians with important insights into factors associated with chronic prescription opioid use, with past chronic prescription opioid use being the most important.

Measuring Overweight and Obesity in Persons with Spinal Cord Injury: What Do Health Providers Use and What are the Challenges?

INTRODUCTION

Obesity is a significant health concern for veterans and individuals with spinal cord injury, yet screening for overweight/obesity can be challenging. This study examines how healthcare providers screen for overweight/obesity and the challenges encountered in identifying overweight/obesity in veterans and persons with spinal cord injury.

MATERIALS AND METHODS

Healthcare providers who provide care for persons with spinal cord injury completed a semi-structured interview. The interview explored their perspectives on measuring overweight/obesity in persons with spinal cord injury and the challenges they faced. Thematic analysis was used to identify themes that emerged from the interviews.

RESULTS

Twenty-five providers (88% female with an average experience of 9.6 ± 7.3 years in providing care for spinal cord injury patients) participated in the interviews. The themes described the health indicators and equipment used to assess overweight/obesity, provider concerns regarding measurement, and criteria for classifying overweight/obesity. Body weight and body mass index were the most commonly used indicators. However, concerns were raised regarding accuracy of these measures for spinal cord injury patients, as well as issues related to the accessibility, calibration, and usability of the equipment. Many providers reported using standard body mass index ranges and categories instead of those specific to spinal cord injury.

CONCLUSION

This study identified the most commonly used indicators of weight or body composition in veterans and persons with spinal cord injury and highlighted providers' concerns with these measures. Future research is needed to identify the most feasible, accurate, and appropriate health indicators that could be used in a clinical setting to identify overweight and obesity in this population.

Association of Calcium and Vitamin D Supplements with Fractures in Persons with a Traumatic SCI

Background

Osteoporotic fractures occur in almost half of patients with a spinal cord injury (SCI) and are associated with significant morbidity and excess mortality. Paralyzed Veterans Administration (PVA) guidelines suggest that adequate calcium and vitamin D intake is important for skeletal health, however, the association of these supplements with osteoporotic fracture risk is unclear.

Objectives

To determine the association of filled prescriptions for calcium and vitamin D with fracture risk in Veterans with an SCI.

Methods

The 5897 persons with a traumatic SCI of at least 2 years' duration (96% male; 4% female) included in the VSSC SCI/D Registry in FY2014 were followed from FY2014 to FY2020 for incident upper and lower extremity fractures. Filled daily prescriptions for calcium or vitamin D supplements for ≥6 months with an adherence ≥80% were examined.

Results

Filled prescriptions for calcium (hazard ratio [HR] 0.65; 95% CI, 0.54-0.78) and vitamin D (HR 0.33; 95% CI, 0.29-0.38) supplements were associated with a significantly decreased risk for incident fractures.

Conclusion

Calcium and vitamin D supplements are associated with decreased risk of fracture, supporting PVA guidelines that calcium and vitamin D intake are important for skeletal health in persons with an SCI.

Factors associated with perceived social isolation among veterans with spinal cord injury and disorders: Cross sectional survey

CONTEXT/OBJECTIVE

Examine demographics, injury characteristics, objective measures of social isolation and health factors that are associated with perceived social isolation (PSI) among Veterans with spinal cord injury and disorders (SCI/D).

DESIGN

Cross-sectional survey.

SETTING

The Veterans Health Administrations (VHA) SCI/D system of care.

PARTICIPANTS

Veterans with SCI/D who have used the VHA health care system.

INTERVENTION

Not applicable.

OUTCOMES MEASURES

We assessed unadjusted associations of high PSI (above population mean) vs low (normative/below population mean), and multivariable logistic regression for independent associations with PSI.

RESULTS

Out of 1942 Veterans with SCI/D, 421 completed the survey (22% response rate). Over half (56%) had PSI mean scores higher than the general population. Among the objective measures, having a smaller social network size was associated with increased odds of high PSI (OR 3.59, P < .0001); additionally, for health factors, having depression (OR 3.98, P < 0.0001), anxiety (OR 2.29, P = 0.009), and post-traumatic stress (OR 2.56, P = 0.003) in the previous 6 months, and having 4 or more chronically occurring secondary conditions (OR 1.78, P = 0.045) was associated with increased odds of high PSI. The most commonly identified contributors to feelings of PSI included mobility concerns (63%), having a SCI/D (61%), and concerns about being a burden on others (57%).

CONCLUSIONS

Factors such as social network size may be used to identify individuals with SCI/D at risk for PSI. Additionally, by identifying mental health problems, presence of multiple chronically occurring secondary conditions, and Veteran-identified contributors of PSI, we can target these factors in a patient-centered interventions to identify and reduce PSI.