Patients' perspective on the comprehensive preventive health evaluation in veterans with spinal cord injury

International Spinal Cord Injury Community Survey: Socioeconomic and Healthcare Satisfaction in Spain

STUDY DESIGN

Survey study.

OBJECTIVES

People living with spinal cord injury (SCI) are major healthcare and rehabilitation services consumers and have unmet healthcare needs. This study aimed to describe the socioeconomic characteristics of people living with SCI in Spain and to determine the level of use and satisfaction with the public healthcare system.

METHODS

We conducted a survey (the Spanish version of the International Spinal Cord Injury Community Survey) consisting of 134 questions. We analyzed the age, sex, neurological classification of the injury on the American Spinal Injury Association Impairment Scale, time of injury, socio-occupational and socioeconomic status, and level of use and satisfaction with the public health system.

RESULTS

472 people responded to the survey [68.9% male; mean age 51.2 years (standard deviation: 13.9 years); 61.7% with paraplegia and 38.3% with tetraplegia]. 89.2% of those surveyed were unemployed and 77.1% received a disability pension. The number of medical visits was 2.3/year, and 19.8% of the patients required at least 1 hospital admission during the previous year. 94.7% of the people with SCI considered the health care received as good or very good.

CONCLUSIONS

Respondents with SCI in Spain considered they had good access to primary and specialized care and were satisfied with the healthcare system. Notably, we observed a high average of annual visits to medical professionals but a low rate of hospitalizations. Technical aids and state services related to disability should be the most important elements to be improved.

Primary Care in the Spinal Cord Injury Population: Things to Consider in the Ongoing Discussion

Purpose of Review

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population.

Findings

Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population.

Summary

Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

The functioning of social support in long-term prevention after spinal cord injury. A qualitative study

BACKGROUND

The impact of social support on the long-term condition after a spinal cord injury (SCI) varies across studies mainly involving self-report questionnaires.

OBJECTIVE

We aimed to establish the common factors associated with social support leading individuals with an SCI to the effective prevention of secondary complications, including via adherence to medical follow-up.

METHODS

Inclusion criteria were a history of acquired SCI of any etiology, wheelchair use, and age≥18 years at the time of the study. Participants should have completed their initial rehabilitation program in France≥1 year earlier and were also enrolled according to 2 related study variables: routine medical follow-up (patients were or were not followed up) and the medically supervised reporting of a pressure ulcer after the initial rehabilitation session (0 or≥1 pressure ulcers). We performed a preparatory quantitative and qualitative literature review to identify factors affecting long-term follow-up after SCI, then adopted a narrative design with semi-structured interviews, transcribed and analyzed progressively by using qualitative analysis software.

RESULTS

We included 32 participants. We categorized our results based on the knowledge, attitudes, beliefs and practices of participants with respect to pressure ulcer prevention and long-term medical follow-up. Our narrative approach allowed us to identify 3 main domains relevant to social support: reciprocity, self-management and timing related to social support.

CONCLUSIONS

Our study showed social support as a dynamic process, a reciprocal phenomenon evolving in variations over time. These findings should be central to short- and long-term therapeutic education programs for patients and for people providing social support. Effective changes should also be implemented through the concept of the Learning Health System.

Documentation of weight management practices for individuals with spinal cord injuries and disorders

STUDY DESIGN

This cross-sectional chart review study included 100 US Veterans with spinal cord injuries/disorders (SCI/D) who received care at a Veterans Affairs (VA) SCI facility during a 12-month period. Progress notes were examined to extract need for weight management (WM), patient-provider discussions about risk due to overweight/obesity, recommended lifestyle changes and/or follow-up and WM education.

OBJECTIVES

To understand what WM services are offered to Veterans with SCI/D within the VA SCI System of Care during comprehensive preventive health evaluations (annual evaluations), inpatient stays and outpatient visits.

SETTING

VA SCI System of Care, Department of Veterans Affairs, United States.

RESULTS

Overall, 73% demonstrated a need for WM. Weight was most frequently addressed during the nutrition assessment of annual evaluations, but this assessment was most likely to be skipped. Nutrition histories were missing many key components. Over half received WM education; individuals who were described as overweight/obese by their provider were more likely to receive education. Most of the Veterans who were seen in an inpatient setting were weighed; weight was only discussed with 12%. Less than half of the Veterans with outpatient visits were weighed, and 23% received WM recommendations.

CONCLUSIONS

Weight was frequently discussed during nutrition assessments, but infrequently addressed during outpatient or inpatient encounters. Few Veterans received specific recommendations on caloric/nutrient requirements and nutrition histories were missing recommended elements. Additional work is needed to help providers to incorporate WM information into care.

Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI

OBJECTIVE

Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters.

DESIGN/SETTING/PARTICIPANTS

Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011.

OUTCOME MEASURES

Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented).

RESULTS

Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants' were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk.

CONCLUSION

Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention.

Colonoscopy is high yield in spinal cord injury

OBJECTIVES/BACKGROUND

Colorectal cancer (CRC) can be prevented by routine colonoscopy. CRC screening in special populations, e.g. spinal cord injury and disorders, presents unique barriers and, potentially, a higher risk of complications. We were concerned about potentially higher risks of complications and sought to determine the safety of colonoscopy.

METHODS

Retrospective observational design using medical record review for 311 patients who underwent 368 colonoscopies from two large VA SCI centers from 1997-2008. Patient demographics and peri-procedural characteristics, including indication, bowel prep quality, and pathological findings are presented. Descriptive statistics are presented.

RESULTS

The population was predominantly male and Caucasian, and 199 (64%) had high-level injuries (T6 or above). Median age at colonoscopy was 61 years (interquartile range 53-69). Just <1/2 of the colonoscopies were diagnostic, usually for evidence of rectal bleeding. Although a majority of colonoscopies were reported as poorly prepped, the proportion that were adequately prepped increased over time (from 3.7 to 61.3%, P = <0.0001). Of the 146 polyps removed, 101 (69%) were adenomas or carcinomas. Ten subjects had 11 complications, none of which required surgical intervention.

CONCLUSIONS

Although providing quality colonoscopic care in this population is labor intensive, the data suggests that it appears safe and therapeutically beneficial. The results indicate that the risk of screening is outweighed by the likelihood of finding polyps. Recognition of the benefit of colonoscopy in this population may have improved bowel prep and reporting over time. Spinal cord injury providers should continue to offer screening or diagnostic colonoscopy to their patients when indicated, while being aware of the special challenges that they face.

Potentially modifiable risk factors among veterans with spinal cord injury hospitalized for severe pressure ulcers: a descriptive study

CONTEXT/OBJECTIVE

Pressure ulcers (PrUs) are a serious, costly and potentially life-long complication of spinal cord injury (SCI). Co-morbid conditions increase PrU risk, adding to the health behavior challenges faced by people with SCI. Little is known about medical co-morbidities, health beliefs, risk, protective behaviors, and readiness to improve skin care behaviors in people with SCI. This study describes the potentially modifiable medical and behavioral risk factors among veterans with SCI and severe (Stage III/IV) PrUs.

DESIGN

Cross-sectional observational design.

SETTING

6 VA SCI Centers.

PARTICIPANTS

Convenience sample from a larger intervention study of 148 veterans hospitalized for PrUs.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Knowledge, PrU risk, skin protective behaviors, health beliefs, and practices, health locus of control, skin worsening.

RESULTS

Most ulcers were stage IV (73%) and about half had 2+ PrUs. Participants reported a mean of 6.7 co-morbid conditions (respiratory, gastrointestinal, renal disease/urinary tract infection, autonomic dysreflexia, diabetes, bowel/bladder incontinence). Potential intervention opportunities include proactive assistance with management of multiple chronic conditions, substance abuse, nutrition, adherence to skin protective behaviors, readiness to change, and access to resources. Overall knowledge about PrUs was low, especially for how to prevent PrUs and what to do if skin breakdown occurs.

CONCLUSION

Future research should address whether comprehensive models that include patient self-management, decision support and health care system, and proactive behavior change assistance for patients help reduce PrU incidence and recurrence in persons with SCI.

TRIAL REGISTRATION

http://clinicaltrials.gov/ct2/show/NCT00105859.

Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series

Background

Continuing challenges to timely adoption of evidence-based clinical practices in healthcare have generated intense interest in the development and application of new implementation methods and frameworks. These challenges led the United States (U.S.) Department of Veterans Affairs (VA) to create the Quality Enhancement Research Initiative (QUERI) in the late 1990s. QUERI's purpose was to harness VA's health services research expertise and resources in an ongoing system-wide effort to improve the performance of the VA healthcare system and, thus, quality of care for veterans. QUERI in turn created a systematic means of involving VA researchers both in enhancing VA healthcare quality, by implementing evidence-based practices, and in contributing to the continuing development of implementation science.

The efforts of VA researchers to improve healthcare delivery practices through QUERI and related initiatives are documented in a growing body of literature. The scientific frameworks and methodological approaches developed and employed by QUERI are less well described. A QUERI Series of articles in Implementation Science will illustrate many of these QUERI tools. This Overview article introduces both QUERI and the Series.

Methods

The Overview briefly explains the purpose and context of the QUERI Program. It then describes the following: the key operational structure of QUERI Centers, guiding frameworks designed to enhance implementation and related research, QUERI's progress and promise to date, and the Series' general content. QUERI's frameworks include a core set of steps for diagnosing and closing quality gaps and, simultaneously, advancing implementation science. Throughout the paper, the envisioned involvement and activities of VA researchers within QUERI Centers also are highlighted. The Series is then described, illustrating the use of QUERI frameworks and other tools designed to respond to implementation challenges.

Conclusion

QUERI's simultaneous pursuit of improvement and research goals within a large healthcare system may be unique. However, descriptions of this still-evolving effort, including its conceptual frameworks, methodological approaches, and enabling processes, should have applicability to implementation researchers in a range of health care settings. Thus, the Series is offered as a resource for other implementation research programs and researchers pursuing common goals in improving care and developing the field of implementation science.

Clinical assessment and management of obesity in individuals with spinal cord injury: a review

BACKGROUND

Diagnosing and managing obesity in individuals with spinal cord injury (SCI) remain challenging.

METHODS

Literature on the epidemiology, impact, and management of obesity in individuals with SCI was reviewed.

FINDINGS

Although nearly 66% of individuals with SCI are either overweight or obese, little guidance is available to measure and monitor obesity in the clinical setting. The use of anthropometric indices and specific cut points available for able-bodied persons is limited by the body composition changes that follow SCI. Indices of upper body obesity warrant examination in SCI because they provide an index of central obesity, which is more closely linked to some obesity-related conditions than is overall obesity. Investigations into the sequelae of excess body fat and its distribution are also needed in SCI because past research in this area has been inconclusive. Although limited, evidence regarding obesity interventions in SCI may be promising.

CONCLUSIONS

The best anthropometric tool to define obesity in the clinical setting remains unknown. SCI-specific assessment tools and a better understanding of the sequelae of excess body weight will lead to better targeting of prevention and treatment efforts. More research is needed on the individual components of a weight management program unique to SCI. Until then, providers are urged to use a team approach and draw on existing resources and applicable research in able-bodied individuals to facilitate weight management in individuals with SCI.

Spinal cord injury medicine. 5. Long-term medical issues and health maintenance

This self-directed learning module highlights long-term care issues in patients with spinal cord injury (SCI). It is part of the study guide on SCI in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The most common secondary medical complications include pressure ulcers, pneumonia, and genitourinary issues. Health care maintenance is important to prevent medical complications, for general health as well as for issues specific to SCI. Women with SCI have gender-specific issues regarding amenorrhea, sexuality, fertility, and menopause. Options exist to assist disabled men with sexuality and fertility complications. Pain is a common complication after SCI. Many new areas of research in the field of SCI are discussed.

OVERALL ARTICLE OBJECTIVE

To discuss long-term care issues in patients with spinal cord injury, including health maintenance, secondary conditions, women's health, sexual function, pain, and spinal cord regeneration and recovery.

Evaluation of Selected Laboratory Components of a Comprehensive Periodic Health Evaluation for Veterans With Spinal Cord Injury and Disorders

OBJECTIVE

To evaluate selected laboratory components of a comprehensive periodic health evaluation program for patients with spinal cord injury and disorders (SCI/D).

DESIGN

A retrospective study.

SETTING

A Department of Veterans Affairs spinal cord injury center.

PARTICIPANTS

Community-dwelling male veterans with SCI/D (N=350).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Proportion of laboratory tests that resulted in new diagnoses (diagnostic yield) and proportion of laboratory tests that resulted in changes in management (therapeutic yield).

RESULTS

Although abnormality rates for many routine laboratory tests were high (up to 31.5%), diagnostic and therapeutic yields were low (<1.5%), with the exception of glucose (therapeutic yield, 3.4%) and lipid tests (up to a 4.1% diagnostic and 15.2% therapeutic yield).

CONCLUSIONS

Our data revealed that diagnostic and therapeutic yields for many laboratory components of the annual PHE program for veterans with SCI/D were low, consistent with findings in the general ambulatory population. Further data collection, particularly prospective longitudinal data, may help optimize the selection and frequency of laboratory tests performed as part of this program.