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IIR 01-199 – HSR&D Study

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IIR 01-199
Stroke Prevention, Incidence and Outcomes in Veterans with Diabetes
Thomas W Findley MD PhD
East Orange Campus of the VA New Jersey Health Care System, East Orange, NJ
East Orange, NJ
Funding Period: October 2002 - March 2009

BACKGROUND/RATIONALE:
Veterans with diabetes currently account for approximately 50% of all individuals with strokes within the VHA. Research has been limited in the area of understanding of the incidence and outcomes of stroke among veterans with diabetes, including the role of stroke prevention activities through the adherence to cardiovascular risk reduction and rehabilitation interventions. This is particularly important since persons with diabetes already have at least one risk factor for stroke by virtue of their disease, and that is estimated that approximately 20% of VHA users in FY 2000 had diabetes.

OBJECTIVE(S):
Aim 1. Describe the epidemiology of diabetes related stroke in the VHA.
Aim 2. Assess quality of care provided by the VHA in terms of medical prevention quality of care, the construction of summary scales, the use of functional outcome data, and the influence external accreditation practices on stroke rehabilitation and outcomes and the impact of admission volume on stroke prevention practices.
Aim 3. Prediction modeling of stroke incidence and mortality and functional status of patients who incur a stroke.

METHODS:
This project used a retrospective analysis of Diabetes Epidemiologic Cohort (DEpiC) utilizing merged Medicare and VHA databases. To take advantage of the availability of Medicare data from FY97-00, we developed a FY97/FY98 diabetes cohort to model incident and subsequent stroke over 27months. We also took advantage of the LVHS and more complete FIM data for 2001. Finally, a comprehensive chart review tool was developed with a chart abstractions made with that data recorded in a separate database.

FINDINGS/RESULTS:
Prevalence of Inadequate Hypertension Control: Blood pressure values in excess of national guidelines are common after both stroke and MI; however fewer stroke patients achieved blood pressure control. Fewer patients who had a stroke were prescribed 2 antihypertensive agents despite the higher average blood pressure in this group. (Roumie et al, 2007)

VA-Medicare Beneficiaries With Stroke Location of Care: Most patients received their incident stroke hospital care in Medicare, but a majority sought VA care afterward. The VA provided an intensive inpatient care for stroke patients. (Shen et al, 2005)

Use of Risk Adjustment Models to Predict Stroke Mortality: Comorbidities that were significant and were reported in statistical models of stroke mortality included dementia, atrial fibrillation, as well as respiratory and cardiovascular diagnoses. (Maney et al, 2004)

IMPACT:
The burden of stroke in a diabetic population is a significant one, particularly for the VA where Veterans with diabetes currently account for approximately 50% of all individuals with strokes within the VA. The study of veterans following initial stroke is essential given the risk for secondary stroke and other health concerns. The simultaneous use of care both inside and outside of the VA system needs to be considered when providing care to these veterans with stroke. All records, both Medicare and VA, must be reviewed to ensure comprehensive and not duplicative care. The project developed a chart review tool that is available for VA researcher use.

PUBLICATIONS:

Journal Articles

  1. Shen Y, Findley PA, Maney M, Pogach L, Crystal S, Rajan M, Findley TW. Department of Veterans Affairs-Medicare dual beneficiaries with stroke: where do they get care? Journal of rehabilitation research and development. 2008 Jan 1; 45(1):43-51.
Conference Presentations

  1. Roumie C, Greevy R, Maney M, Findley TW. Prevalence of inadequate hypertension control among veterans after a major cardiovascular event. Presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 27; Toronto, Canada.
  2. Roumie C, Greevy R, Maney M, Findley TW. Prevalence of Inadequate Hypertension Control among Diabetics after a Major Cardiovascular Event. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 13; Arlington, VA.
  3. Shen Y, Findley P, Maney MA, Rajan M, Pogach L, Crystal S, Findley T. VA-Medicare Beneficiaries With Stroke: Where Do They Get Care. Paper presented at: VA HSR&D National Meeting; 2005 Feb 2; Baltimore, MD.
  4. Agbaje I, Quigley K, Maney M, Natelson B, Findley TW. Quantitative Balance and Self-Reported Health Status in Medically Unexplained Illness. Poster session presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2004 Oct 6; Phoenix, AZ.
  5. Findley T, Quigley K, Maney M, Chaudhry H, Agbaje I. Improvement in Balance with Structural Integration (Rolfing): A Controlled Case Series in persons with myofascial pain. Poster session presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2004 Oct 6; Phoenix, AZ.
  6. Maney M, Findley P, Sambamoorthi U, Findley T. Use of Risk Adjustment Models to Predict Stroke Mortality. Paper presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2004 Oct 6; Phoenix, AZ.


DRA: none
DRE: Epidemiology
Keywords: Diabetes, Stroke
MeSH Terms: none

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