Adaptation for sustainability in an implementation trial of team-based collaborative care

Background

Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM).

Method

Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively).

Results

Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time.

Conclusions

EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.

Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT

INTRODUCTION

The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes.

STUDY DESIGN

A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic.

SETTING/PARTICIPANTS

Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149).

INTERVENTION

Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration.

MAIN OUTCOME MEASURES

Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed.

RESULTS

For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57).

CONCLUSIONS

Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT04106193.

Patient and provider predictors of telemental health use prior to and during the COVID-19 pandemic within the Department of Veterans Affairs

The current study examined patient and provider differences in use of phone, video, and in-person mental health (MH) services. Participants included patients who completed ≥ 1 MH appointment within the Department of Veterans Affairs (VA) from 10/1/17-7/10/20 and providers who completed ≥ 100 VA MH appointments from 10/1/17-7/10/20. Adjusted odds ratios (aORs) are reported of patients and providers: (a) completing ≥1 video MH appointment in the pre-COVID (10/1/17-3/10/20) and COVID (3/11/20-7/10/20) periods; and (b) completing the majority of MH visits via phone, video, or in-person during COVID. The sample included 2,480,119 patients/31,971 providers in the pre-COVID period, and 1,054,670 patients/23,712 providers in the COVID period. During the pre-COVID and COVID periods, older patients had lower odds of completing ≥ 1 video visit (aORs < .65). During the COVID period, older age and low socioeconomic status predicted lower odds of having ≥ 50% of visits via video versus in-person or phone (aORs < .68); schizophrenia and MH hospitalization history predicted lower odds of having ≥ 50% of visits via video or phone versus in-person (aORs < . 64). During the pre-COVID and COVID periods, nonpsychologists (e.g., psychiatrists) had lower odds of completing video visits (aORs < . 44). Older providers had lower odds of completing ≥ 50% of visits via video during COVID (aORs <. 69). Findings demonstrate a digital divide, such that older and lower income patients, and older providers, engaged in less video care. Nonpsychologists also had lower video use. Barriers to use must be identified and strategies must be implemented to ensure equitable access to video MH services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Rapid Increase in Telemental Health Within the Department of Veterans Affairs During the COVID-19 Pandemic

Background: The use of telemental health via videoconferencing (TMH-V) became critical during the Coronavirus disease 2019 (COVID-19) pandemic due to restriction of non-urgent in-person appointments. The current brief report demonstrates the rapid growth in TMH-V appointments in the weeks following the pandemic declaration within the Department of Veterans Affairs (VA), the largest healthcare system in the United States. Methods: COVID-19 changes in TMH-V appointments were captured during the six weeks following the World Health Organization's pandemic declaration (March 11, 2020-April 22, 2020). Pre-COVID-19 TMH-V encounters were assessed from October 1, 2017 to March 10, 2020. Results: Daily TMH-V encounters rose from 1,739 on March 11 to 11,406 on April 22 (556% growth, 222,349 total encounters). Between March 11-April 22, 114,714 patients were seen via TMH-V, and 77.5% were first-time TMH-V users. 12,342 MH providers completed a TMH-V appointment between March 11-April 22, and 34.7% were first-time TMH-V users. The percentage growth of TMH-V appointments was higher than the rise in telephone appointments (442% growth); in-person appointments dropped by 81% during this time period. Discussion and Conclusions: The speed of VA's growth in TMH-V appointments in the wake of the COVID-19 pandemic was facilitated by its pre-existing telehealth infrastructure, including earlier national efforts to increase the number of providers using TMH-V. Longstanding barriers to TMH-V implementation were lessened in the context of a pandemic, during which non-urgent in-person MH care was drastically reduced. Future work is necessary to understand the extent to which COVID-19 related changes in TMH-V use may permanently impact mental health care provision.

Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record

IMPORTANCE

Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures.

OBJECTIVE

To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review.

EXPOSURES

CIED procedure.

MAIN OUTCOMES AND MEASURES

The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries).

RESULTS

The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.

External Determinants of Veterans' Utilization of VA Health Care

OBJECTIVE

Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, "external determinants"), including the 2014 Medicaid expansion following the Affordable Care Act.

DATA SOURCES/STUDY SETTING

We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014).

STUDY DESIGN

For veterans aged 18-64 and ≥65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects.

PRINCIPAL FINDINGS

All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs).

CONCLUSIONS

Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.

Factors associated with internal medicine physician job attitudes in the Veterans Health Administration

Background

US healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA).

Methods

A cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation.

Results

A total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures.

Conclusions

Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3015-z) contains supplementary material, which is available to authorized users.

Does adding clinical data to administrative data improve agreement among hospital quality measures?

BACKGROUND

Hospital performance measures based on patient mortality and readmission have indicated modest rates of agreement. We examined if combining clinical data on laboratory tests and vital signs with administrative data leads to improved agreement with each other, and with other measures of hospital performance in the nation's largest integrated health care system.

METHODS

We used patient-level administrative and clinical data, and hospital-level data on quality indicators, for 2007-2010 from the Veterans Health Administration (VA). For patients admitted for acute myocardial infarction (AMI), heart failure (HF) and pneumonia we examined changes in hospital performance on 30-d mortality and 30-d readmission rates as a result of adding clinical data to administrative data. We evaluated whether this enhancement yielded improved measures of hospital quality, based on concordance with other hospital quality indicators.

RESULTS

For 30-d mortality, data enhancement improved model performance, and significantly changed hospital performance profiles; for 30-d readmission, the impact was modest. Concordance between enhanced measures of both outcomes, and with other hospital quality measures - including Joint Commission process measures, VA Surgical Quality Improvement Program (VASQIP) mortality and morbidity, and case volume - remained poor.

CONCLUSIONS

Adding laboratory tests and vital signs to measure hospital performance on mortality and readmission did not improve the poor rates of agreement across hospital quality indicators in the VA.

INTERPRETATION

Efforts to improve risk adjustment models should continue; however, evidence of validation should precede their use as reliable measures of quality.

Team Process Variation Across Diabetes Quality of Care Trajectories

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

How pooling fragmented healthcare encounter data affects hospital profiling

OBJECTIVES

People receiving healthcare from multiple payers (eg, Medicare and the Veterans Health Administration [VA]) have fragmented health records. How the use of more complete data affects hospital profiling has not been examined.

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined 30-day mortality following acute myocardial infarction at 104 VA hospitals for veterans 66 years and older from 2006 through 2010 who were also Medicare beneficiaries. Using VA-only data versus combined VA/Medicare data, we calculated 2 risk-standardized mortality rates (RSMRs): 1 based on observed mortality (O/E) and the other from CMS' Hospital Compare program, based on model-predicted mortality (P/E). We also categorized hospital outlier status based on RSMR relative to overall VA mortality: average, better than average, and worse than average. We tested whether hospitals whose patients received more of their care through Medicare would look relatively better when including those data in risk adjustment, rather than including VA data alone.

RESULTS

Thirty-day mortality was 14.8%. Adding Medicare data caused both RSMR measures to significantly increase in about half the hospitals and decrease in the other half. O/E RSMR increased in 53 hospitals, on average, by 2.2%, and decreased in 51 hospitals by -2.6%. P/E RSMR increased, on average, by 1.2% in 56 hospitals, and decreased in the others by -1.3%. Outlier designation changed for 4 hospitals using O/E measure, but for no hospitals using P/E measure.

CONCLUSIONS

VA hospitals vary in their patients' use of Medicare-covered care and completeness of health records based on VA data alone. Using combined VA/Medicare data provides modestly different hospital profiles compared with those using VA-alone data.

Associations with chest illness and mortality in chronic spinal cord injury

OBJECTIVE

Identify factors associated with chest illness and describe the relationship between chest illness and mortality in chronic spinal cord injury (SCI).

DESIGN

Cross-sectional survey assessing chest illness and a prospective assessment of mortality.

METHODS

Between 1994 and 2005, 430 persons with chronic SCI (mean ± SD), 52.0 ± 14.9 years old, and ≥4 years post SCI (20.5 ± 12.5 years) underwent spirometry, completed a health questionnaire, and reported any chest illness resulting in time off work, indoors, or in bed in the preceding 3 years. Deaths through 2007 were identified. Outcome measures Logistic regression assessing relationships with chest illness at baseline and Cox regression assessing the relationship between chest illness and mortality.

RESULTS

Chest illness was reported by 139 persons (32.3%). Personal characteristics associated with chest illness were current smoking (odds ratio =2.15; 95% confidence interval =1.25-3.70 per each pack per day increase), chronic obstructive pulmonary disease (COPD) (3.52; 1.79-6.92), and heart disease (2.18; 1.14-4.16). Adjusting for age, subjects reporting previous chest illness had a non-significantly increased hazard ratio (HR) for mortality (1.30; 0.88-1.91). In a multivariable model, independent predictors of mortality were greater age, SCI level and completeness of injury, diabetes, a lower %-predicted forced expiratory volume in 1 second, heart disease, and smoking history. Adjusting for these covariates, the effect of a previous chest illness on mortality was attenuated (HR = 1.15; 0.77-1.73).

CONCLUSION

In chronic SCI, chest illness in the preceding 3 years was not an independent risk factor for mortality and was not associated with level and completeness of SCI, but was associated with current smoking, physician-diagnosed COPD, and heart disease history.

Multisensory impairment reported by veterans with and without mild traumatic brain injury history

With the use of Veterans Health Administration and Department of Defense databases of veterans who completed a Department of Veterans Affairs comprehensive traumatic brain injury (TBI) evaluation, the objectives of this study were to (1) identify the co-occurrence of self-reported auditory, visual, and vestibular impairment, referred to as multisensory impairment (MSI), and (2) examine demographic, deployment-related, and mental health characteristics that were potentially predictive of MSI. Our sample included 13,746 veterans with either a history of deployment-related mild TBI (mTBI) (n = 9,998) or no history of TBI (n = 3,748). The percentage of MSI across the sample was 13.9%, but was 17.4% in a subsample with mTBI history that experienced both nonblast and blast injuries. The factors that were significantly predictive of reporting MSI were older age, being female, lower rank, and etiology of injury. Deployment-related mTBI history, posttraumatic stress disorder, and depression were also significantly predictive of reporting MSI, with mTBI history the most robust after adjusting for these conditions. A better comprehension of impairments incurred by deployed servicemembers is needed to fully understand the spectrum of blast and nonblast dysfunction and may allow for more targeted interventions to be developed to address these issues.

Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: a gender comparison

BACKGROUND

Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI.

METHODS

This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms.

FINDINGS

Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains.

CONCLUSION

Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI.

Systemic inflammation and reduced pulmonary function in chronic spinal cord injury

OBJECTIVE

To evaluate the relationship between systemic inflammation and pulmonary function in persons with chronic spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

Fifty-nine men with chronic SCI participating in a prior epidemiologic study.

METHODS

Standardized assessment of pulmonary function and measurement of plasma C-reactive protein (CRP) and interleukin-6 (IL-6).

MAIN OUTCOME MEASUREMENTS

Forced expiratory volume in 1 second (FEV(1)) and forced vital capacity (FVC).

RESULTS

Persons with the highest values of IL-6 had the lowest %-predicted FEV(1) and FVC. There was a significant inverse linear trend between quartile of IL-6 and %-predicted FEV(1) (P < .001) and FVC (P < .006), unadjusted and adjusted for SCI level and completeness of injury, obstructive lung disease history, smoking, and body mass index (P = .010-.039). Although not as strong as for IL-6, there also were similar trends for %-predicted FEV(1) and FVC with CRP.

CONCLUSIONS

In chronic SCI, higher levels of IL-6 and CRP were associated with a lower FEV(1) and FVC, independent of level and completeness of injury. These results suggest that the reduction of pulmonary function after SCI is related not only to neuromuscular impairment but also to factors that promote systemic inflammation.

Job satisfaction of primary care team members and quality of care

In recent years, hospitals and payers have increased their efforts to improve the quality of patient care by encouraging provider adherence to evidence-based practices. Although the individual provider is certainly essential in the delivery of appropriate care, a team perspective is important when examining variation in quality. In the present study, the authors modeled the relationship between a measure of aggregate job satisfaction for members of primary care teams and objective measures of quality based on process indicators and intermediate outcomes. Multilevel analyses indicated that aggregate job satisfaction ratings were associated with higher values on both types of quality measures. Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care.

Risk factors for chest illness in chronic spinal cord injury: a prospective study

OBJECTIVE

Chest illnesses commonly cause morbidity in persons with chronic spinal cord injury. Risk factors remain poorly characterized because previous studies have not accounted for factors other than spinal cord injury.

DESIGN

Between 1994 and 2005, 403 participants completed a respiratory questionnaire and underwent spirometry. Participants were contacted at a median of 1.7 yrs [interquartile range: 1.3-2.5 yrs] apart over a mean (SD) of 5.1 +/- 3.0 yrs and asked to report chest illnesses that had resulted in time off work, spent indoors, or in bed since prior contact.

RESULTS

In 97 participants, there were 247 chest illnesses (0.12/person-year) with 54 hospitalizations (22%). Spinal cord injury level, completeness of injury, and duration of injury were not associated with illness risk. Adjusting for age and smoking history, any wheeze (relative risk = 1.92; 95% confidence interval: 1.19, 3.08), pneumonia or bronchitis since spinal cord injury (relative risk = 2.29; 95% confidence interval: 1.40, 3.75), and physician-diagnosed chronic obstructive pulmonary disease (relative risk = 2.17; 95% confidence interval: 1.08, 4.37) were associated with a greater risk of chest illness. Each percent-predicted decrease in forced expiratory volume in 1 sec was associated with a 1.2% increase in risk of chest illness (P = 0.030).

CONCLUSIONS

In chronic spinal cord injury, chest illness resulting in time spent away from usual activities was not related to the level or completeness of spinal cord injury but was related to reduced pulmonary function, wheeze, chronic obstructive pulmonary disease, a history of pneumonia and bronchitis, and smoking.

Satisfaction of women urologists with maternity leave and childbirth timing

PURPOSE

Women physicians must consider many conflicting issues when timing childbirth. We characterized maternity leave, breast-feeding practices and satisfaction associated with pregnancy timing in women urologists.

MATERIALS AND METHODS

A 114-item anonymous survey including questions on maternity leave duration for firstborn children, workplace policies, attitudes and satisfaction was mailed to all 365 American board certified women urologists in May and July 2007. Logistic regression was used to identify factors associated with greater satisfaction.

RESULTS

A total of 243 women urologists (69%) responded, of whom 158 had at least 1 biological child. Average maternal age at first birth was 32.6 years. Of the children 10%, 32% and 52% were born before, during and after residency, respectively. Only 42% of women reported the existence of a formal maternity leave policy. Of the women 70% took 8 weeks or less of leave. Those with 9 weeks or greater were 3.8 times more likely to report satisfaction (p = 0.001). Although women in practice were 2.0 times more likely to take 9 weeks or greater compared to those in training or earlier (p = 0.046), only 30% in practice took this much time. Dissatisfaction with leave was not related to birth timing (residency vs practice) or maternal age at delivery but to work/residency related issues in 69% of respondents, financial concerns in 13% and personal/other in 18%. For breast-feeding 67% of respondents were satisfied with the duration and 22% were not. Dissatisfaction was secondary to work factors.

CONCLUSIONS

Satisfaction with leave was related to the amount of maternity leave with women with 9 weeks or greater more likely to report satisfaction. Women in practice were more likely to take 9 weeks or greater but most did not due to strong stressors related to work, partners/peers or finances. Work factors were cited for dissatisfaction with breast-feeding.

Dual energy x-ray absorptiometry of the distal femur may be more reliable than the proximal tibia in spinal cord injury

OBJECTIVE

To evaluate the precision of dual energy x-ray absorptiometry scanning at 2 skeletal sites at the knee (proximal femur and distal tibia) in people with SCI.

DESIGN

Cross-sectional.

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

Subjects (N=20) with chronic SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Precision as determined by root mean square coefficient of variation (RMS-CV) and root mean square standard deviation (RMS-SD).

RESULTS

At the distal femur the root RMS-CV was 3.01% and the RMS-SD was 0.025g/cm2. At the proximal tibia the RMS-CV was 5.91% and the RMS-SD was 0.030g/cm2.

CONCLUSIONS

Precision at the distal femur is greater than at the proximal tibia and we recommend it as the preferred site for the longitudinal assessment of bone mineral density at the knee in chronic SCI.

Osteoporotic fractures and hospitalization risk in chronic spinal cord injury

Osteoporosis is a well acknowledged complication of spinal cord injury. We report that motor complete spinal cord injury and post-injury alcohol consumption are risk factors for hospitalization for fracture treatment. The clinical assessment did not include osteoporosis diagnosis and treatment considerations, indicating a need for improved clinical protocols.

INTRODUCTION

Treatment of osteoporotic long bone fractures often results in lengthy hospitalizations for individuals with spinal cord injury. Clinical features and factors that contribute to hospitalization risk have not previously been described.

METHODS

Three hundred and fifteen veterans > or = 1 year after spinal cord injury completed a health questionnaire and underwent clinical exam at study entry. Multivariate Cox regression accounting for repeated events was used to assess longitudinal predictors of fracture-related hospitalizations in Veterans Affairs Medical Centers 1996-2003.

RESULTS

One thousand four hundred and eighty-seven hospital admissions occurred among 315 participants, and 39 hospitalizations (2.6%) were for fracture treatment. Median length of stay was 35 days. Fracture-related complications occurred in 53%. Independent risk factors for admission were motor complete versus motor incomplete spinal cord injury (hazard ratio = 3.73, 95% CI = 1.46-10.50). There was a significant linear trend in risk with greater alcohol consumption after injury. Record review indicated that evaluation for osteoporosis was not obtained during these admissions.

CONCLUSIONS

Assessed prospectively, hospitalization in Veterans Affairs Medical Centers for low-impact fractures is more common in motor complete spinal cord injury and is associated with greater alcohol use after injury. Osteoporosis diagnosis and treatment considerations were not part of a clinical assessment, indicating the need for improved protocols that might prevent low-impact fractures and related admissions.

VA-based survey of osteoporosis management in spinal cord injury

OBJECTIVE

Although osteoporosis is common following spinal cord injury (SCI), no guidelines exist for its treatment, diagnosis, or prevention. The authors hypothesized that wide variations in diagnosis and treatment practices result from the absence of guidelines. This study sought to characterize the diagnosis and management practices within the VA health care system for osteoporosis following SCI.

DESIGN

Online survey regarding osteoporosis management in SCI composed of 27 questions designed to gather information on responder demographics, osteoporosis diagnostics, and treatment options.

SETTING

VA health care system.

PARTICIPANTS

VHA National SCI Staff Physicians and VHA National SCI Nurses (total n = 450) were sent an email with an invitation to participate.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Practice patterns were assessed, including factors associated with ordering a clinical workup and prescribing osteoporosis treatment.

RESULTS

The response rate was 28%. Ninety-two prescribing practitioners (physicians, nurse practitioners, and physician assistants) were included in the analysis. Of these respondents, 50 (54%) prescribe medications for SCI-induced bone loss; 39 (42%) prescribe bisphosphonates and 46 (50%) prescribe vitamin D. There were 54 (59%) respondents who routinely order diagnostic tests, including dual energy x-ray absorptiometry scans in 50 (54%). Variations in practice were not explained by age, gender, or years practicing SCI medicine. Many respondents (23%) reported barriers to osteoporosis testing including lack of scanning protocols, cost, wheelchair inaccessibility of scanning facilities, and lack of effective treatment guidelines once osteoporosis is diagnosed.

CONCLUSIONS

Despite an absence of screening and treatment guidelines, more than half of all respondents are actively diagnosing and treating osteoporosis with bisphosphonates within the VA health care setting. These data suggest that evidence-based practice guidelines are necessary to reduce practice variations and improve clinical care for this population.

VA-based survey of osteoporosis management in spinal cord injury

OBJECTIVE

Although osteoporosis is common following spinal cord injury (SCI), no guidelines exist for its treatment, diagnosis, or prevention. The authors hypothesized that wide variations in diagnosis and treatment practices result from the absence of guidelines. This study sought to characterize the diagnosis and management practices within the VA health care system for osteoporosis following SCI.

DESIGN

Online survey regarding osteoporosis management in SCI composed of 27 questions designed to gather information on responder demographics, osteoporosis diagnostics, and treatment options.

SETTING

VA health care system.

PARTICIPANTS

VHA National SCI Staff Physicians and VHA National SCI Nurses (total n = 450) were sent an email with an invitation to participate.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Practice patterns were assessed, including factors associated with ordering a clinical workup and prescribing osteoporosis treatment.

RESULTS

The response rate was 28%. Ninety-two prescribing practitioners (physicians, nurse practitioners, and physician assistants) were included in the analysis. Of these respondents, 50 (54%) prescribe medications for SCI-induced bone loss; 39 (42%) prescribe bisphosphonates and 46 (50%) prescribe vitamin D. There were 54 (59%) respondents who routinely order diagnostic tests, including dual energy x-ray absorptiometry scans in 50 (54%). Variations in practice were not explained by age, gender, or years practicing SCI medicine. Many respondents (23%) reported barriers to osteoporosis testing including lack of scanning protocols, cost, wheelchair inaccessibility of scanning facilities, and lack of effective treatment guidelines once osteoporosis is diagnosed.

CONCLUSIONS

Despite an absence of screening and treatment guidelines, more than half of all respondents are actively diagnosing and treating osteoporosis with bisphosphonates within the VA health care setting. These data suggest that evidence-based practice guidelines are necessary to reduce practice variations and improve clinical care for this population.

Longitudinal change in FEV1 and FVC in chronic spinal cord injury

RATIONALE

Although respiratory dysfunction is common in chronic spinal cord injury (SCI), determinants of longitudinal change in FEV(1) and FVC have not been assessed.

OBJECTIVES

Determine factors that influence longitudinal lung function decline in SCI.

METHODS

A total of 174 male participants (mean age of 49 and 17 yr after injury) completed a respiratory questionnaire and underwent spirometry over an average follow-up of 7.5 years (range, 4-14 yr).

MEASUREMENTS AND MAIN RESULTS

In multivariate models, longitudinal decline in FEV(1) was significantly related to continued smoking, persistent wheeze, an increase in body mass index, and respiratory muscle strength. Aging was associated with an accelerated decline in FEV(1) (for ages <40, 40-60, >60 yr: -27, -37, and -71 ml/yr, respectively). Similar effects were observed for FVC.

CONCLUSIONS

Longitudinal change in FEV(1) and FVC was not directly related to level and severity of SCI, but was attributable to potentially modifiable factors in addition to age. These results suggest that weight control, smoking cessation, trials directed at the recognition and treatment of wheeze, and efforts to improve respiratory muscle strength may slow lung function decline after SCI.

Trends in kidney transplantation rates and disparities

OBJECTIVE

To examine the likelihood of transplantation and trends over time among persons with end-stage renal disease (ESRD) in Wisconsin.

METHODS

We examined the influence of patient- and community-level characteristics on the rate of kidney transplantation in Wisconsin among 22,387 patients diagnosed with ESRD between January 1, 1982 and October 30, 2005. We grouped patients by the year of ESRD onset in order to model the change in transplantation rates over time.

RESULTS

After multivariate adjustment, all other racial groups were significantly less likely to be transplanted compared with whites, and the racial disparity increased over calendar time. Older patients were less likely to be transplanted in all periods. Higher community income and education level and a greater distance from patients' residence to the nearest dialysis center significantly increased the likelihood of transplantation. Males also had a significantly higher rate of transplantation than females.

CONCLUSION

These results demonstrate a growing disparity in transplantation rates by demographic characteristics and a consistent disparity in transplantation by socioeconomic characteristics. Future studies should focus on identifying specific barriers to transplantation among different subpopulations in order to target effective interventions.

The increasing incidence of end-stage renal disease in Wisconsin from 1982-2003: an analysis by age, race, and primary diagnosis

PURPOSE

To examine the trends in the incidence of end-stage renal disease in Wisconsin from 1982 to 2003.

METHODS

De-identified incidence data for this study were supplied by the Renal Network of the Upper Midwest (Region 11). We examined trends in the incidence of end-stage renal disease by age, race, gender, and primary diagnosis from 1982 to 2003.

RESULTS

The incidence of end-stage renal disease increased more than 3-fold from 1982 to 2003. This increase was especially striking in persons with diabetes and hypertension, as well as among those aged > or = 75 years. The increase in the incidence of end-stage renal disease was also apparent among all racial groups and both genders.

CONCLUSIONS

The continued increase in the incidence of end-stage renal disease in Wisconsin may result from a number of factors, such as an unintended consequence of better chronic disease management, which may predispose older individuals to end-stage renal disease. Resources aimed at decreasing the incidence of end-stage renal disease are needed to prevent unnecessary health care costs and negative health outcomes, including loss of life.