Leg and arm wounds, with blood vessel injury and high amputation rates, occur in trauma victims and are especially common in injured Service Members from the Iraqi/Afghanistan war (Operations Enduring Freedom/ Iraqi Freedom/New Dawn; OEF/OIF/OND). The high number of limb injuries among OEF/OIF/OND Veterans and their long-term, complex care requirements pose a significant challenge to the VA. Combat-related vascular injuries are present in 12% of this cohort, a rate 5 times higher than in prior wars, and extremity injuries comprise 50-60% of casualties. Improvements in medical and surgical trauma care, including initial in-theatre limb salvage approaches (IILS), have resulted in improved survival and fewer amputations; however, the long-term outcomes such as morbidity, functional decline, and risk for late amputation of salvaged limbs using current process of care have not been studied. Best practices for chronic care after traumatic vascular injury repair is lacking.
We will conduct a study linking initial vascular injuries to long-term outcomes by addressing the following Aims: 1) Compare injury, demographic and geospatial characteristics of patients with initial in-theatre limb salvage (IILS) and identify late vascular surgery related limb complications and health care utilization in Veterans receiving VA care; 2) Characterize the preventive services received by individuals with vascular repair; and 3) Describe patient-reported functional outcomes in Veterans with traumatic vascular limb injuries.
Among Post-9/11 Veterans who receive VA care we developed a cohort who sustained a vascular injury in theatre based on ICD-9-CM codes and procedure codes included in the DoD Trauma Registry (DoDTR) data. We then identified those who initially received a vascular repair and who did not have an amputation. We will obtain injury characteristics from DoDTR, merge DoDTR data with VA inpatient, outpatient, Medicare, and pharmacy data to address our aims. We will use merged VA+Medicare and DoDTR data to identify vascular procedures performed including limb salvage survival time, and indicators of persistent morbidity over time (e.g., frequent/ emergency care for vascular-related conditions, venous stasis disease, long-term opioid therapy [VA patients only]). We will use VA+Medicare administrative databases to identify treatment patterns (use of duplex ultrasound screening, anti-platelet and statin regimens) and associated outcomes (e.g., vascular repair patency) to provide evidence for future development of quality indicators. Finally we will perform a nation-wide survey of Veterans to determine functional outcome using standardized surveys.
Since the start of this project we have confirmed extremety vascular injuries and abstracted the VA medical charts of 386 potential Veteran participants. We have submitted the necessary forms to access Medicare data on these Veterans. We have received IRB amendment approval to send surveys to Veterans without first contacting the Veteran by telephone which has improved our survey response rate.
This project will contribute to understanding the complex needs of these Veterans, will allow better long-term care, as well as inform planning for resource utilization within the VA and DoD systems. Moreover, findings will inform the Polytrauma System of Care (PSoC) on how to provide the best care for these individuals by optimizing long-term outcomes and avoiding complications and morbidity. Because long-term outcomes of vascular repair for extremity trauma are lacking for civilian and military trauma patients, data from this study could also affect the acute and long-term care of trauma patients in the civilian sector and define parameters for the use of pharmacologic agents and rehabilitation programs.
- Shireman PK, Rasmussen TE, Jaramillo CA, Pugh MJ. VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration. BMC surgery. 2015 Feb 3; 15:13.