Developing a national registry of veterans with spinal cord dysfunction: experiences and implications

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

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Co-occurring medical and mental illness and substance use disorders among veteran clinic users with spinal cord injury patients with complexities

STUDY DESIGN

Longitudinal analysis of SCI registry merged with VHA administrative-data and Medicare claims files (FY1999-2002).

OBJECTIVES

To estimate the prevalence of mental illness (MI) and substance use disorders (SUDs) among veteran health administration (VHA) clinic users with spinal cord injuries (SCI) and examine subgroup variations by demographic, socioeconomic characteristics, and duration and level of SCI.

SETTING

VHA clinic users (N=8338) with SCI who were alive by the end of FY2002.

METHODS

ICD-9-CM codes were used to identify individual MI (anxiety disorders, bipolar, depressive disorders, psychoses, post-traumatic stress disorder (PTSD) and schizophrenia) and categories of SUDs (tobacco, alcohol and drug abuse). Chi-square tests and multinomial logistic regression were used to examine the demographic and socio-economic profile of VHA users with SCI and MI and/or SUD.

RESULTS

Over a 2-year period, 46% VHA users with SCI had either a MI or SUDs: 20% had MI only; 12% had SUD only and 14% had both. The most common MI was depressive disorder (27%) and tobacco use was highly prevalent (19%). African-Americans (versus whites) were less likely to be diagnosed with MI only. Increased duration of SCI lowered the likelihood of MI and/or SUDs. Mood and anxiety disorders were highly prevalent in veterans with SCI with chronic physical conditions such as diabetes, heart disease, hypertension, and respiratory diseases.

CONCLUSIONS

Mental illness and SUDs are highly prevalent in the VHA population with SCI and is complicated by the high rates of chronic physical conditions, presenting challenges in their healthcare management.

The Sonya Slifka Longitudinal Multiple Sclerosis Study: methods and sample characteristics

The Sonya Slifka Longitudinal Multiple Sclerosis Study follows a population-based cohort of approximately 2000 people with multiple sclerosis (MS) to study demographic and clinical characteristics, course of illness, utilization and cost of health services, provider characteristics, use of MS specialists and disease modifying agents, and neurologic, economic and psychosocial outcomes. This report describes the study methodology, presents baseline demographic and clinical data, and evaluates the representativeness of the sample. A stratified random sample of persons with established and recently-diagnosed MS selected from the National Multiple Sclerosis Society (NMSS) mailing lists was supplemented with recently-diagnosed patients recruited through systematic nationwide outreach. Baseline data were collected by computer-assisted telephone interviews derived from standardized instruments; data collection continues at six-month intervals. The cohort was comparable to population-based and clinical samples with respect to demographics, course, relapse rate, symptoms, and severity of disability. Almost two-thirds of the cohort needed help with activities of daily living, three-quarters were limited in work or other activities, and half had emotional problems that compromised quality of life. The Slifka Study cohort is broadly representative of the MS population and the database can be used to address questions not answered by natural history studies, clinical databases, or population-based surveys.

Evaluating diagnosis-based risk-adjustment methods in a population with spinal cord dysfunction

OBJECTIVE

To examine performance of models in predicting health care utilization for individuals with spinal cord dysfunction.

DESIGN

Regression models compared 2 diagnosis-based risk-adjustment methods, the adjusted clinical groups (ACGs) and diagnostic cost groups (DCGs). To improve prediction, we added to our model: (1) spinal cord dysfunction-specific diagnostic information, (2) limitations in self-care function, and (3) both 1 and 2.

SETTING

Models were replicated in 3 populations.

PARTICIPANTS

Samples from 3 populations: (1) 40% of veterans using Veterans Health Administration services in fiscal year 1997 (FY97) (N=1,046,803), (2) veteran sample with spinal cord dysfunction identified by codes from the International Statistical Classification of Diseases, 9th Revision, Clinical Modifications (N=7666), and (3) veteran sample identified in Veterans Affairs Spinal Cord Dysfunction Registry (N=5888).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Inpatient, outpatient, and total days of care in FY97.

RESULTS

The DCG models (R(2) range,.22-.38) performed better than ACG models (R(2) range,.04-.34) for all outcomes. Spinal cord dysfunction-specific diagnostic information improved prediction more in the ACG model than in the DCG model (R(2) range for ACG,.14-.34; R(2) range for DCG,.24-.38). Information on self-care function slightly improved performance (R(2) range increased from 0 to.04).

CONCLUSIONS

The DCG risk-adjustment models predicted health care utilization better than ACG models. ACG model prediction was improved by adding information.

Relationship between self-reported disability and caregiver hours

OBJECTIVE

In a large, population-based cohort of patients with spinal cord dysfunction, we assessed the relationship between self-reported physical function and hours of care received.

DESIGN

Data were obtained by a cross-sectional, self-administered survey used to help establish a national registry of veterans with spinal cord dysfunction. Participants were originally identified from Department of Veterans Affairs databases as having a high probability of spinal cord dysfunction. All 13,542 respondents reporting spinal cord dysfunction and also having complete data on physical function and caregiver hours (CGHs) were included. Physical function was measured using the Self-Reported Functional Measure, and CGHs were obtained from a self-report of hours of caregiving received during the last 2 wk.

RESULTS

The relationship between self-reported disability and CGHs was strong (Spearman correlation = -0.70). Subjects with moderate levels of disability had the most variability in CGHs. After stratifying by total Self-Reported Functional Measure score, the strongest predictors of CGHs were instrumental activities of daily living and individual Self-Reported Functional Measure items, explaining a moderate amount of variation in CGHs.

CONCLUSION

These data support the construct validity of the Self-Reported Functional Measure and suggest that self-reported disability measures can be of use in describing the clinical epidemiology of patients with spinal cord dysfunction.

The self-reported functional measure: Predictive validity for health care utilization in multiple sclerosis and spinal cord injury

OBJECTIVE

To examine the predictive validity of the Self-Reported Functional Measure (SRFM), a new measure derived from the FIMtrade mark instrument, for health care utilization in multiple sclerosis (MS) and spinal cord injury (SCI).

DESIGN

Prospective cohort study using a mailed survey in 1995 and administrative records from 1996 and 1997.

SETTING

Veterans Health Administration hospitals and outpatient clinics.

PATIENTS

A total of 6361 veterans with SCI and 1789 veterans with MS.

MAIN OUTCOME MEASURES

SRFM score was compared with subsequent outpatient visits, hospitalizations, hospital lengths of stay (LOSs), and residence peri-hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these variables.

RESULTS

A total of 3836 subjects (47.6%) were hospitalized during 1996-1997, and all but 874 (10.7%) had 1 or more outpatient visits. SRFM score predicted inpatient, but not outpatient health care utilization. Persons in the lowest SRFM quartile were over 90% (OR = 1.91, 95% CI = 1.71-2.13) more likely to be hospitalized compared with those in the highest SRFM quartile; also, they were over 2 times (OR = 2.18, 95% CI = 1.85-2.57) more likely to have a LOS greater than 7 days, were over 2 times (OR = 2.41, 95% CI = 1.62-3.58) more likely to die in hospital, and were nearly 3 times (OR = 2.86, 95% CI = 2.00-4.08) more likely to be discharged to an institution.

CONCLUSIONS

SRFM had excellent predictive validity for hospitalization, LOS, and discharge destination among patients with MS or SCI.

A model of outcomes research: spinal cord injury

OBJECTIVE

To use spinal cord injury (SCI) care and research as a paradigm to illustrate how the principles and practices of outcomes research have been and can be applied to the sequelae of a specific disability.

DATA SOURCES

Review of data sources and literature pertaining to outcomes of SCI.

STUDY SELECTION

English language literature, health status and health services research agencies, academic and governmental research, and surveillance settings.

DATA EXTRACTION

A critical review of measures that have been and may be used to measure the outcomes of SCI. Special attention was paid to data sources; the need for methodologic accommodations: the research balance between generic and condition-specific methods; and the measurement outcomes that are highly relevant to people with SCIs.

DATA SYNTHESIS

There is a substantial research record related to the natural history, rehabilitation, survival, and long-term social reintegration of people with SCI, but relatively less addressing widely used generic health outcomes.

CONCLUSION

Contemporary outcomes research is relevant to people with SCI and those who provide treatment. One area of special attention is the occurrence of secondary conditions. To a large extent, SCI outcomes research can use conventional methods and generic instruments. There also is a need to modify research methods and to refine and apply some measures specific to people with SCI.

Department of Veterans Affairs Quality Enhancement Research Initiative for spinal cord injury

Spinal cord injury (SCI) is a lifelong condition, requiring ongoing efforts by multiple disciplines to stabilize, diminish, or prevent impairments; avoid or limit secondary complications; and improve or maintain social role functioning and quality of life for the individual throughout his or her life. There are approximately 200,000 persons with SCI in the United States, of whom roughly 22% are veterans. The estimated national economic impact of SCI is approximately $9.73 billion per year. These figures illustrate why SCI is an important topic for the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI). The SCI QUERI will identify gaps in knowledge of SCI treatment and management, develop research efforts to address these gaps, identify best practices for care and management of SCI, and assess whether best practices lead to improved outcomes, including health-related quality of life.

The validity in persons with spinal cord injury of a self-reported functional measure derived from the functional independence measure

STUDY DESIGN

A cross-sectional, mailed survey on impairment and function using 6361 respondents to the Spinal Cord Dysfunction National Veterans Survey who reported spinal cord injury as the sole cause of their spinal cord dysfunction.

OBJECTIVES

To establish the concurrent and construct validities of a Self-Reported Functional Measure appropriate for use in patients with spinal cord injuries.

SUMMARY OF BACKGROUND DATA

Functional assessment is of increasing importance in clinical care, quality assurance, and national health-care planning. There is a conspicuous need for validated functional assessment measures that are rapid, reliable, and appropriate for use in the disabled population.

METHODS

The correlation was examined of hours of personal assistance, number of affected limbs, amount of motor impairment, and amount of combined limb-motor impairment to Self-Reported Functional Measure response tertile (scores, 13-32, 33-45, 46-52; lower scores indicated worse function).

RESULTS

There were statistically significant correlations between Self-Reported Functional Measure score and hours of personal assistance (P < 0.001), the number of affected limbs (P < 0.001), the amount of motor impairment (P < 0.001), and the amount of combined limbmotor impairment (P < 0.001). For example, 87% of people with the most limb-motor impairment (four affected limbs and no useful movement) were in the lowest Self-Reported Functional Measure tertile, compared with 3% of people in the least-affected category of limb-motor impairment. Furthermore, visual, sensory, or memory impairment did not influence the correlation between limbmotor impairment and Self-Reported Functional Measure score.

CONCLUSION

The Self-Reported Functional Measure shows good concurrent and construct validities.