Lead/Presenter: Mary Jo Pugh, COIN - Salt Lake City
All Authors: Pugh MJ (Informatics, Decision-Enhancement and Analytic Sciences Center), Copeland LA (Western Massachusetts VA Health Care System), Bollinger MJ (Center for Mental Healthcare and Outcomes Research) Amuan ME (Informatics, Decision-Enhancement and Analytic Sciences Center) Rivera JC (Sinai Hospital, Lifebridge Health System) Paula K. Shireman (South Texas Veterans Healthcare System)
The high number of limb injuries among Post-9/11 deployed Veterans and their long-term care requirements pose a significant challenge to clinicians. Current follow-up for patients with traumatic vascular injury repair (TVR) is based on best practices for treatment of peripheral vascular disease (PVD), e.g., antiplatelet/statin therapy, annual duplex ultrasound. No best practices exist for TVR. Our goal was to determine use of PVD best practices provided to Post-9/11 Veterans with combat-related TVR.
We identified Post-9/11 Veterans with vascular injury undergoing an initial attempt at repair in the DoD trauma registry (DoDTR) and validated by chart abstraction. Validated cases were merged with VA administrative data to characterize the cohort, describe treatment, and identify complications associated with TVR based on CPT codes and medications prescribed.
Characteristics of the 527 individuals with validated vascular injury included active duty (84%), Caucasian (77%), mean age at injury of 25.2 years, with a mean of 13 months between injury and entering VA care. Mechanism of injury was explosive (63%), bullet (32%) and other (5%); 90% of injuries were battle-related. Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%); 65% were medically retired. Approximately 6.5% received scheduled VA vascular specialty care, 8% received ultrasound evaluation of vascular status, 5% received statins, and 11% received anticoagulant or antiplatelet therapy at any time during the first five years of VA care. However, complications included urgent or emergency vascular care (5%), acute infection (10%), chronic infection (1%), diagnosed indicators of venous stasis (24.5%), and paresthesia/neuropathy (27%).
Despite the injury severity of TVR (40% moderate/severe), fewer than 10% of the vascular cohort received regular VA vascular care, at most 11% received care concordant with PVD quality measures in the VA, and approximately a quarter had some indicator of adverse outcome from vascular injury.
The treatment gap in Veterans with TVR appears to be due to lack of vascular specialty care or Veterans accessing care outside of the VA. Linking health system data (processes of care) with outcomes from longitudinal follow-up will help define optimal care processes for combat Veterans with vascular repair.