Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

CDA 17-170 – HSR&D Study

New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects

CDA 17-170
Optimizing Bacteriuria Management in Veterans with Spinal Cord Injury
Felicia Skelton MD
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: November 2017 - October 2022

BACKGROUND/RATIONALE:
Bacteriuria, ether asymptomatic (ASB) or symptomatic urinary tract infection (UTI) is common in persons SCI. Current Veterans Health Administration (VHA) guidelines recommend a screening urine culture for every Veteran with SCI during their annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use. As the clinical outcomes of the annual exam testing have not been explored, we theorize some Veterans are receiving antibiotics unnecessarily. The negative consequences of antibiotic overuse and antibiotic resistance are well documented, and have a national and even global focus.

OBJECTIVE(S):
AIM 1: Identify patient, provider and facility factors driving bacteriuria management in persons with SCI, utilizing qualitative and quantitative methods. We will explore providers' and patients' knowledge and attitudes towards urine testing at the annual examination through Sub-aims 1 and 2.

Sub-aim1a: Conduct nationwide, semi-structured interviews at SCI centers.
Qualitative Research Questions: What do patients and providers understand about the risks and benefits of urine testing during the annual evaluation and the use of antibiotics to treat bacteriuria?
Sub-aim1b: Administer validated quantitative surveys to patients and providers that measure medication adherence and knowledge of ASB guidelines, respectively.
Hypothesis 1b: Patient medication adherence scores and provider ASB knowledge scores will be low.

AIM 2: Using a national administrative database, we will determine which a) patient, provider and facility factors are predictors of urine testing and subsequent antibiotic use during the annual evaluation and b) compare the clinical outcomes of those who received antibiotics with those who did not.
Hypothesis 2a: Patient factors (age), provider factors (SCI-related training) and facility factors (hub versus spoke) will predict both urine testing and subsequent antibiotic prescription to treat bacteriuria.
Hypothesis 2b: Patients who receive antibiotics to treat urinary bacteria after the annual examination will have similar rates of healthcare utilization for genitourinary complaints compared with those who do not.

AIM 3: Develop the "Test Smart, Treat Smart" intervention, and conduct a feasibility trial of its use during the SCI annual evaluation. Sub-aim 3a: For providers, we will refine the validated "Kicking CAUTI" intervention for the SCI population; Sub-aim3b: For patients, we will develop education materials focusing on neurogenic bladder and bacteriuria management. Sub-aim3c: Conduct a feasibility trial of the intervention at the Houston VA looking at intervention burden for providers and patient satisfaction with bladder education during the annual evaluation and overall quality of life (QOL) in regards to bladder management.
Hypothesis 3: Providers will describe low user burden with the intervention through qualitative interviews. Patients will report high satisfaction with neurogenic bladder and bacteriuria information received during the annual evaluation.

METHODS:
Conceptual Framework

Cabana et al. and others have explored the barriers to successful implementation of clinical practice guidelines into actual practice. Clinical practice guidelines for bacteriuria management are often long and complex, requiring users to keep a mental record of sequential of the statements to arrive at the diagnosis of UTI or ASB. We will utilize the Cabana model to understand provider barriers to using clinical practice guidelines in clinical practice. During the development of the intervention (Aim 3), we will use the concept of intervention mapping described by Kok et al., as well as audit and feedback, as a main component of the intervention. Audit and feedback, or providing healthcare professionals with up-to-date data about their performance, has previously been shown to improve quality of care.

Aim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation using qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination, and compare the clinical outcomes of those who received antibiotics to those who did not. Aim 3 will use the information gathered from the previous aims to develop the "Test Smart, Treat Smart" intervention, a combination of patient and provider education and resources that will help all stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.


FINDINGS/RESULTS:
Not yet available.

IMPACT:
Bacteriuria management in persons with SCI is a routine task that involves complex decision-making to be handled in a guidelines compliant manner, particularly given conflicting guidelines on this topic. We have developed regional and national partners on this work to increase likelihood of wide-spread adoption. We hope to guide policy reform surrounding this common, but burdensome condition.

PUBLICATIONS:

Journal Articles

  1. Skelton F, Martin LA, Evans CT, Kramer J, Grigoryan L, Richardson P, Kunik ME, Poon IO, Holmes SA, Trautner BW. Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study. JMIR research protocols. 2019 Feb 14; 8(2):e12272.
  2. Skelton F, Suda K, Evans C, Trautner B. Effective antibiotic stewardship in spinal cord injury: Challenges and a way forward. The journal of spinal cord medicine. 2019 Mar 1; 42(2):251-254.
  3. Skelton F, Grigoryan L, Holmes SA, Poon IO, Trautner B. Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions. Archives of physical medicine and rehabilitation. 2018 Feb 1; 99(2):219-225.


DRA: Health Systems, Brain and Spinal Cord Injuries and Disorders, Cardiovascular Disease
DRE: Prognosis, TRL - Applied/Translational
Keywords: none
MeSH Terms: none