BACKGROUND/RATIONALE:
Pressure ulcers are a serious, costly, and life-long complication of spinal cord injury (SCI). Pressure ulcer prevalence has been estimated at between 17 and 33% among persons with SCI residing in the community. Epidemiological studies have found that 36-50% of all persons with SCI who develop pressure ulcers will develop a recurrence within the first year after initial healing (Carlson et al., 1992; Fuhrer et al., 1993; Goldstein, 1998; Niazi et al., 1997; Salzberg et al. 1998). Recurrence rates have ranged from 21% to 79%, regardless of treatment (Schryvers et al., 2000; Goodman et al., 1999; Niazi et al., 1997). Pressure ulcer treatment is expensive. Surgical costs associated with pressure ulcer treatment can exceed $70,000 per case (Braun et al., 1992). VA administrative (National Patient Care Database, NPCD) data indicate that 41% of inpatient days in the SCI population are accounted for by either primary or secondary diagnoses of pressure ulcers or 23% of SCI inpatient days if restricted to primary diagnoses of pressure ulcers. Pressure ulcer recurrence has been associated with many factors including previous pressure ulcer surgery (Niazi et al., 1997). Although little data exist describing the factors associated with recurrence following surgery, some investigators reported recurrence rates of 11%-29% in cases with post-operative complications and 6% to 61% in cases without post-operative complications (Mandrekas & Mastorakos, 1992; Relander & Palmer, 1988; Disa et al., 1992). In a retrospective study of 48 veterans with SCI, investigators reported a 79% recurrence rate following surgery (Goodman et al., 1999).

OBJECTIVE(S):
The purpose of this project was to identify effective interventions for reducing recurrent pressure ulcers, a severe costly complication in veterans with SCI. The effect of an educational and structured telephone counseling follow-up program on prevention and health care utilization were being evaluated. Hypotheses included the following: 1) After discharge from the hospital for treatment of a severe healed pelvic pressure ulcer, patients receiving the education and structured telephone counseling intervention would be significantly less likely to develop a new or recurrent severe (e.g., Stage III or IV), pelvic (defined for this study as occurring in the sacrum, coccyx, trochanter, or ischium) pressure ulcer than those receiving customary care. 2) Admissions and inpatient days for severe pelvic pressure ulcers will be significantly lower for veterans receiving the education and structured telephone counseling intervention when compared to those receiving customary care.

METHODS:
Veterans admitted to 6 VA SCI Centers for medical and/or surgical treatment of a Stage III or IV pelvic pressure ulcer (sacrum, coccyx, trochanter or ischium) were randomly assigned to (1) an Intervention Group consisting of education plus structured telephone counseling follow-up or (2) a Customary Care (Control) group. Intervention Group subjects received a cognitive behavioral intervention based on the Trans-theoretical Stages of Change Model, which is designed to help individuals identify ways of improving health behaviors. On admission, interviewers collected information on demographics, health status/well being, locus of control, pressure ulcer knowledge, readiness-to-change, and health beliefs/practices. Some of these measures were re-administered prior to randomization and at 9 and 18 months post-discharge. Health care utilization was monitored for all participants for the length of the study. The primary outcome (dependent) variables were (1) the occurrence or non-occurrence of another pelvic pressure ulcer within 18 months of discharge following healing and, (2) for individuals who develop pressure ulcers during the study period, time to recurrence. Intervention Group participants were expected to have fewer pressure ulcer-related admissions and, if admitted, a shorter hospital stay. Secondary outcomes included health care utilization, pressure ulcer prevention knowledge, medical and psychological health status, health beliefs and practices, and quality of life. Multi-variate logistic models are being used to examine factors associated with recurrence and to evaluate the impact of recurrence on health care utilization.

FINDINGS/RESULTS:
Recruitment and randomization did not meet expectations. Reasons included: 1) patients leaving the hospital with the study ulcer unhealed; 2) patients discharged without notice; 3) patients discharged with multiple unhealed ulcers. In addition, some recurrences in both groups have been within the first 3 months after discharge, earlier than expected. The Principal Investigator (PI), Co-Principal Investigator, Site PIs addressed these issues and identified IRB approved mechanisms to improve enrollment and randomization. However, HSR&D at VA Central Office decided to close down this study. All collected data are being entered into databases for analyses, after which they will be used for publications and future projects.

IMPACT:
This project had the potential to reduce the prevalence of pressure ulcers and costly hospitalization and surgery and to result in model programs for preventing recurrence. Unfortunately, we are not able to go forward with this project at this time. However, we are confident that when our data are published, we will have an excellent foundation for future studies in this most critical topic.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Guihan M, Garber SL, Bombardier CH, Durazo-Arizu R, Goldstein B, Holmes SA. Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury. Archives of physical medicine and rehabilitation. 2007 Jul 1; 88(7):858-61. [view]
2. Guihan M, Garber SL, Bombardier CH, Goldstein B, Holmes SA, Cao L. Predictors of pressure ulcer recurrence in veterans with spinal cord injury. The journal of spinal cord medicine. 2008 Jan 1; 31(5):551-9. [view]

Conference Presentations

1. Guihan M, Bates-Jensen BB, Burns SP. Characteristics of Recurrent Pressure Ulcers in Veterans with Spinal Cord Injury. Paper presented at: World Union of Wound Healing Societies Annual Congress; 2008 Jun 4; Toronto, Canada. [view]
2. Guihan M, Bates-Jensen BB, Garber SL, Burns SP. Characteristics of Recurrent Pressure Ulcers in Veterans with Spinal Cord Injury. Paper presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2008 Aug 11; Orlando, FL. [view]
3. Guihan ML, Garber SL, Aftandilian A, Burns SP, Cao L, Durazo-Arvizu R, Goldstein B, Holmes SA, Midha M, Sanford P, Trincher R. Empirical data on veterans with spinal cord injury hospitalized for severe pressure ulcers. Paper presented at: American Paraplegia Society Annual Meeting; 2005 Sep 1; Las Vegas, NV. [view]
4. Guihan ML, Garber SL, Aftandilian A, Burns S, Goldstein B, Holmes SA, Midha M, Sanford P, Trincher R. Factors predicting healing of severe pressure ulcers in veterans with spinal cord injury. Paper presented at: American Congress of Rehabilitation Medicine Annual Meeting; 2005 Sep 1; Chicago, IL. [view]
5. Garber SL, Guihan ML, Goldstein B, Holmes SA, Durazo-Arvizu R, Bombardier CH. Factors Predicting Recurrence of Severe Pressure Ulcers in Veterans with Spinal Cord Injury. Poster session presented at: Advances in Skin and Wound Care Clinical Annual Symposium; 2005 Oct 1; Las Vegas, NV. [view]
6. Bombardier CH, Guihan ML, Garber SL. Preventing Pressure Ulcers in Veterans with Spinal Cord Injury. Paper presented at: American Association of Spinal Cord Injury Psychologists and Social Workers Annual Conference; 2005 Sep 1; Las Vegas, NV. [view]
7. Guihan M, Hastings JD. Roles in Pressure Ulcer Management in Persons with Spinal Cord Injury. Poster session presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2008 Aug 11; Orlando, FL. [view]
8. Guihan ML. Turning a clinical problem into a research question (invited presentation). Paper presented at: American Association of Spinal Cord Injury Psychologists and Social Workers Annual Conference; 2005 Sep 1; Las Vegas, NV. [view]

DRA: Health Systems
DRE: Prevention, Technology Development and Assessment
Keywords: Spinal cord injury, Utilization patterns
MeSH Terms: none