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2023 HSR&D/QUERI National Conference Abstract

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1206 — Factors Associated with Guideline-Discordant Management of Asymptomatic Bacteriuria and Urinary Tract Infections in Veterans with Neurogenic Bladder

Lead/Presenter: Margaret Fitzpatrick,  COIN - Seattle/Denver
All Authors: Fitzpatrick MA (Center of Innovation for Veteran-Centered and Value-Driven Care, Rocky Mountain Regional VA Medical Center), Wirth M (Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital) Solanki P (Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital) Suda KJ (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System) Burns SP (VA Puget Sound Healthcare System) Weaver FM (Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital) Collins E (University of Illinois Chicago College of Nursing) Safdar N (William S. Middleton VA Hospital) Evans CT (Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital)

Objectives:
Guideline-discordant management of asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) is common but has not been well described for patients with bladder dysfunction due to chronic neurologic injury (‘neurogenic bladder’ (NB)). This study assessed factors associated with guideline-discordant management of ASB and UTI in Veterans with NB and explored Veteran experiences with UTI.

Methods:
This mixed methods study included Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), or Parkinson’s disease (PD) at four VA medical centers between 2017-2018 with encounters in any care setting associated with an ASB or UTI diagnosis. Medical record reviews were performed on a sample of 300 encounters (n = 200 UTI; n = 100 ASB) to determine guideline-concordant diagnosis and treatment. Logistic regression models assessed factors associated with inappropriate diagnosis and treatment. Focus group discussions guided by the Health Belief Model are ongoing, with preliminary data presented from five Veterans who participated in the first two focus groups.

Results:
The chart review sample included 116 (38.7%) patients with SCI/D, 106 (35.3%) with MS, and 69 (23%) with PD. Most patients were male, older, and used either indwelling or intermittent bladder catheterization. Most ASB encounters had appropriate diagnosis (98%) and appropriate treatment (92%). 35% of UTI encounters had inappropriate diagnosis, most of which was for patients with true ASB and all of those encounters had inappropriate treatment with antibiotics. 19.5% of UTI encounters with appropriate diagnosis had inappropriate treatment. Patient comorbidities (chronic kidney disease, peripheral vascular disease, cerebrovascular disease) were associated with increased odds of inappropriate management while use of indwelling catheter and physical medicine and rehabilitation (PMandR) provider were associated with decreased odds of inappropriate management. Qualitative data revealed ways that UTIs impact quality of life which may affect patient behavior, with patients expressing difficulty engaging in social activities, traveling, and mobility when experiencing a UTI. Another key theme was barriers to effective patient-provider communication. Patients felt their concerns were not heard by their provider and recognized the importance of “being their own advocate” (FG 3). Furthermore, patients described the importance of caregivers in helping them better understand and interpret education regarding ASB and UTI, a finding specifically relevant to this population with chronic neurologic injury.

Implications:
Up to half of encounters with a UTI diagnosis for patients with NB have guideline-discordant management, and this leads to unnecessary antibiotic use. Comorbidities are associated with greater odds of guideline-discordant management while indwelling catheter use and PMandR provider are associated with lower odds. Barriers exist in patient-provider communication about UTI, and caregivers may help facilitate patient education and behavior change.

Impacts:
Future interventions to improve ASB and UTI management in patients with NB could benefit from: 1.) targeting patients with greater comorbidities; 2.) leveraging PMandR providers as antimicrobial stewardship extenders to other providers; 3.) improving patient-provider communication; and 4.) including caregivers in patient educational activities.