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1.  Developing a Quality Measure for Clinical Inertia in Diabetes Care 
Health Services Research  2005;40(6 Pt 1):1836-1853.
Objective
To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.
Data Sources
Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.
Study Design
Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.
Principal Findings
Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p<.001).
Conclusions
Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
doi:10.1111/j.1475-6773.2005.00436.x
PMCID: PMC1361229  PMID: 16336551
Diabetes mellitus; outcomes assessment; quality of health care
2.  Health Care Costs for Patients With Chronic Spinal Cord Injury in the Veterans Health Administration 
Background/Objective:
Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, >2 years after injury).
Methods:
Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted.
Results:
Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample.
Conclusions:
The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization.
PMCID: PMC2141733  PMID: 18092564
Health economics; Health care costs; Spinal cord injuries; Tetraplegia; Paraplegia; Veterans Administration
3.  Providers' Perceptions of Spinal Cord Injury Pressure Ulcer Guidelines 
Background/Objective:
Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators.
Methods:
This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators.
Results:
The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources.
Conclusions:
Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.
PMCID: PMC2031945  PMID: 17591223
Decubitus ulcer; Skin ulcer; Pressure ulcer; Practice guidelines; Evidence-based medicine; Prevention; Spinal cord injuries
4.  Design and Evaluation of a Stand-Up Motorized Prone Cart 
Background/Objective:
Prone carts are used for mobility by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing.
Design:
Engineering development project with user feedback through questionnaire. Users selected by convenience sampling.
Methods:
A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45° and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veteran's Administration hospitals.
Outcome Measures:
Questionnaire of subjects, both patients and caregivers, who used the cart.
Findings:
Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns.
Conclusion:
This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next-generation prone cart design project.
PMCID: PMC2032000  PMID: 17385270
Spinal cord injuries; Locomotion; Mobility; Osteoporosis; Pressure ulcers; Nursing; Activities of daily living; Bone loss; Self care
5.  Provider Adherence to Implementation of Clinical Practice Guidelines for Neurogenic Bowel in Adults With Spinal Cord Injury 
Background/Objectives:
Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the “Neurogenic Bowel Management in Adults with Spinal Cord Injury” Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine
Methods:
CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention.
Results:
Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1.
Conclusions:
While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.
PMCID: PMC1808267  PMID: 16869086
Spinal cord injuries; Neurogenic bowel; Practice guidelines; Consensus guidelines; Patient education
6.  A Comparison of Patient Outcomes and Quality of Life in Persons With Neurogenic Bowel: Standard Bowel Care Program Vs Colostomy 
Background/Objective:
The purpose of this study was to compare patient outcomes and quality of life for people with neurogenic bowel using either a standard bowel care program or colostomy.
Methods:
We analyzed survey data from a national sample, comparing outcomes between veterans with spinal cord injury (SCI) who perform bowel care programs vs individuals with colostomies. This study is part of a larger study to evaluate clinical practice guideline implementation in SCI. The sample included 1,503 veterans with SCI. The response rate was 58.4%. For comparison, we matched the respondents with colostomies to matched controls from the remainder of the survey cohort. A total of 74 veterans with SCI and colostomies were matched with 296 controls, using propensity scores. Seven items were designed to elicit information about the respondent's satisfaction with their bowel care program, whereas 7 other items were designed to measure bowel-related quality of life.
Results:
No statistically significant differences in satisfaction or quality of life were found between the responses from veterans with colostomies and those with traditional bowel care programs. Both respondents with colostomies and those without colostomies indicated that they had received training for their bowel care program, that they experienced relatively few complications, such as falls as a result of their bowel care program, and that their quality of life related to bowel care was generally good. However, large numbers of respondents with colostomies (n = 39; 55.7%) and without colostomies (n = 113; 41.7%) reported that they were very unsatisfied with their bowel care program.
Conclusion:
Satisfaction with bowel care is a major problem for veterans with SCI.
PMCID: PMC1808270  PMID: 16869085
Colostomy; Spinal cord injuries; Neurogenic bowel; Bowel care; Quality of Life; Life satisfaction; Activities of daily life

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