The VA vascular injury study: A glimpse at quality of care in Veterans with traumatic vascular injury repair. Issue 6 (June 2022)

• Record Type: Journal Article
• Authors: Copeland, Laurel A.; Pugh, Mary Jo; Bollinger, Mary J.; Wang, Chen-Pin; Amuan, Megan E.; Rivera, Jessica C.; Shireman, Paula K.
• Is Part Of: Injury. Volume 53:Issue 6(2022)
• Page Start: 1947
• Page End: 1953
• Publication Date: 2022-06
• Subjects: Arterial -- Extremities -- Vascular system injuries -- War-related injuries -- Veterans; Wounds and injuries -- Surgery -- Periodicals; Accidents -- Periodicals; Wounds and Injuries -- surgery -- Periodicals; Lésions et blessures -- Chirurgie -- Périodiques; Electronic journals; Electronic journals; 617.1
• DOI: 10.1016/j.injury.2022.04.002
• Languages: English
• ISSNs: 0020-1383

Abstract

Highlights: No best practices exist for arterial extremity injury; those for treatment of peripheral vascular disease (PVD) may be applied. Veterans health administration promotes whole health encompassing physical and psychological health. Veterans ( n = 490) with arterial extremity injury experienced a 46% complications rate over 5 years post-repair. 77% were treated for mental or behavioral disorders; 25% received opioids 90+ days; 25% received guideline-concordant care. Both opioids and guideline-concordant care processes were associated with complications. Abstract: Objective: The high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI. Materials and methods: We identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics. Results: The 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18–56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD. Conclusion: Despite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders. Impact: The treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI.