Due to the high frequency and potential for poor outcomes, respiratory impairments are a high priority for implementation efforts as part of the Spinal Cord Injury (SCI) QUERI strategic plan. This project addressed Steps 2 and 3 of the QUERI process as they apply to four high-risk respiratory conditions for veterans with spinal cord injuries and disorders (SCI&D).
1) To examine current practice patterns for tobacco cessation screening, counseling and treatment, community acquired pneumonia (CAP) diagnosis and treatment, sleep apnea screening, diagnosis and treatment, chronic obstructive pulmonary disease (COPD) diagnosis and treatment, and determine the extent to which practice patterns differ from published guidelines for each of these conditions (QUERI steps 2 & 3); 2) To identify reasons why veterans with SCI&D do not receive evidence-based guideline recommended care for tobacco cessation, CAP, sleep apnea, and COPD, and categorize barriers to providing evidence-based care at the patient, provider, system and guideline levels for each of these conditions (QUERI step 2). Hypotheses included: 1) Provision of guideline recommended care for tobacco cessation, CAP, sleep apnea and COPD in veterans with SCI&D is low; 2) Barriers to guideline-recommended care exist at the patient, provider, system and guideline level. The long-term goal of this work is to increase the use of evidence-based care and improve patient outcomes.
This was a two-year observational study of current practices in respiratory care management and barriers to evidence-based care in the VA SCI&D population. Seven VA SCI Centers served as study sites. To address study objectives, data was collected from multiple data sources since the data needed to examine current practices related to screening, diagnosis and management of the study conditions were not available from a single source. Data sources included a survey of veterans with SCI&D to assess self-reported presence of conditions and their experiences and beliefs with regard to barriers to receipt of evidence-based care; VA administrative data and chart reviews to identify and study cases of CAP, sleep apnea, COPD, and current and recent tobacco users; and semi-structured interviews conducted with SCI&D health care providers to understand current practices and identify barriers to evidence-based care. Analyses included descriptive and nonparametric tests, logistic regressions and qualitative analyses of semi-structured interview data.
Survey results indicated that 29% of veterans with SCI&D are current smokers and that over half had tried to quit smoking during the prior year. For the chart review cohort (n=607), 93% had been screened for smoking status during the prior year. Counseling to quit was documented during a hospitalization for over half (53%) of the recent quitters and current smokers, while counseling was documented for 70% of outpatient visits. Over one-third (35%) of veterans with SCI&D had a documented sleep apnea diagnosis in the past year according to the chart review, but only 17% of survey respondents self-reported that a doctor had ever told them that they had sleep apnea. Of the patients in the survey sample who were at high risk of sleep apnea according to the Epworth Sleepiness Scale, 28% reported having been tested for sleep apnea. Approximately a third of survey respondents indicated that they had ever been told they had pneumonia. The majority of pneumonia cases identified through chart review (84%) were treated as inpatients. Only 11% of hospitalizations had documentation of a sputum culture, and there was documentation of a blood culture in 14% of hospitalizations. Antibiotics within 24 hours occurred in over 80% of cases. Seven percent self-reported having complications with COPD during the prior year. There was documentation of COPD for 42% of the subjects that had chart reviews; 43% were also identified as current smokers and 58% of those individuals were counseled to quit smoking.
Respiratory conditions continue to be a significant concern in veterans with SCI&D. Proportions of current smokers are higher in veterans with SCI&D than in the general veteran population and there is variability in provision of evidence-based care. Efforts to reduce smoking may require the use of combinations of strategies, such as motivational interviewing, improved and equitable access to care, and reduced variability across sites. Sleep apnea and associated sleep disorders are more common conditions in SCI&D than in the general population. Screening of sleep apnea in this population is low and strategies to encourage increased use in this population are needed. There is room for improvement in the treatment of sleep apnea in persons with SCI&D; it is necessary to address the unique challenges experienced within this population. Pneumonia in persons with SCI&D is typically treated in the inpatient setting. However, difficulties in obtaining sputum cultures may affect treatment decisions. The reasons for the observed low rate of blood cultures are unknown and suggest significant room for improvement. Finally, COPD is a bigger problem than has been documented previously and appears to be related to the higher smoking rate in the SCI&D population. Efforts to reduce smoking should help to improve quality of life in this cohort of patients.
- Weaver FM, Smith B, LaVela SL, Evans CT, Ullrich P, Miskevics S, Goldstein B, Strayer J, Burns SP. Smoking behavior and delivery of evidence-based care for veterans with spinal cord injuries and disorders. The journal of spinal cord medicine. 2011 Jan 1; 34(1):35-45.
- Weaver FM, LaVela SL, Burns SP, Rapacki L, Evans (Mayfield) C, Goldstein B, Smith BM, Miskevics SA. Smoking cessation in Veterans with SCI/D. Paper presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2009 Sep 24; Dallas, TX.
- LaVela SL, Rapacki L, Weaver FM. Enhancing respiratory infection control in high risk health care settings. Poster session presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2009 Sep 23; Dallas, TX.
- Smith BM, Evans (Mayfield) C, Burns SP, Goldstein B, LaVela SL, Rapacki L, Miskevics SA, Ullrich PM, Weaver FM. Life satisfaction in veterans with SCI/D. Paper presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2009 Sep 23; Dallas, TX.
- Smith BM, LaVela SL, Burns SP, Evans CT, Rapacki LM, Miskevics SA, Weaver FM. Measuring Outcomes of Best Practices: The Diener Satisfaction with Life Scale and Spinal Cord Injury. Poster session presented at: VA QUERI National Meeting; 2008 Dec 12; Phoenix, AZ.
- Weaver FM, LaVela SL, Burns SP, Rapacki L, Evans (Mayfield) C, Goldstein B. Smoking Cessation in Veterans with SCI/D. Poster session presented at: VA QUERI National Meeting; 2008 Dec 12; Phoenix, AZ.
Treatment - Observational
Clinical practice guidelines, Comorbidity, Spinal cord injury