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CDA 17-170 – HSR&D Study

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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. Taylor AL, Perret D, Morice K, Zafonte R, Skelton F, Rivers E, Alexander M. Climate Change and Physiatry: A Call to Proportional and Prospective Action. American journal of physical medicine & rehabilitation. 2022 Mar 29.
  2. Poon IO, Skelton F, Bean LR, Guinn D, Jemerson T, Mbue ND, Charles CV, Ndefo UA. A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community. Pharmacy (Basel, Switzerland). 2022 Jan 7; 10(1).
  3. Escalon MX, Houtrow A, Skelton F, Verduzco-Gutierrez M. Health Care Disparities Add Insult to Spinal Cord Injury. Neurology. Clinical practice. 2021 Dec 1; 11(6):e893-e895.
  4. Hines-Munson C, May S, Poon I, Holmes SA, Martin L, Trautner BW, Skelton F. Experiences of veterans with spinal cord injury related to annual urine screening and antibiotic use for urinary tract infections. PM & R : the journal of injury, function, and rehabilitation. 2021 Dec 1; 13(12):1369-1375.
  5. Siddiqui S, Huang D, Touchett H, Skelton F. A Clinical Vignette on Community Transition After Inpatient Rehabilitation for a Veteran With New Spinal Cord Injury-Related Disability During the COVID-19 Pandemic. American journal of physical medicine & rehabilitation. 2021 Jul 1; 100(7):631-632.
  6. Poon IO, Skelton F, Bean LR, Guinn D, Jemerson TL, Mbue ND, Charles CV, Ndefo UA. Building Community-Engaged Multidisciplinary Partnerships to Improve Medication Management in Elderly Patients With Multiple Chronic Conditions. Journal of patient-centered research and reviews. 2021 Apr 19; 8(2):113-120.
  7. Huang D, Siddiqui SA, Touchett HN, Skelton F. Protecting the most vulnerable among us: Access to care and resources for persons with disability from spinal cord injury during the COVID-19 pandemic. PM & R : the journal of injury, function, and rehabilitation. 2021 Jun 1; 13(6):632-636.
  8. Mody L, Akinboyo IC, Babcock HM, Bischoff WE, Cheng VC, Chiotos K, Claeys KC, Coffey KC, Diekema DJ, Donskey CJ, Ellingson KD, Gilmartin HM, Gohil SK, Harris AD, Keller SC, Klein EY, Krein SL, Kwon JH, Lauring AS, Livorsi DJ, Lofgren ET, Merrill K, Milstone AM, Monsees EA, Morgan DJ, Perri LP, Pfeiffer CD, Rock C, Saint S, Sickbert-Bennett E, Skelton F, Suda KJ, Talbot TR, Vaughn VM, Weber DJ, Wiemken TL, Yassin MH, Ziegler MJ, Anderson DJ, SHEA Research Committee. Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology. Infection control and hospital epidemiology. 2022 Feb 1; 43(2):156-166.
  9. Skelton F, May S, Grigoryan L, Poon I, Holmes SA, Martin L, Trautner BW. Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship. PM & R : the journal of injury, function, and rehabilitation. 2020 Dec 1; 12(12):1187-1194.
  10. Skelton F, Salemi JL, Akpati L, Silva S, Dongarwar D, Trautner BW, Salihu HM. Genitourinary Complications Are a Leading and Expensive Cause of Emergency Department and Inpatient Encounters for Persons With Spinal Cord Injury. Archives of physical medicine and rehabilitation. 2019 Sep 1; 100(9):1614-1621.
  11. 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.
  12. 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.
Journal Other

  1. Escalon MX, Houtrow A, Skelton F, Verduzco-Gutierrez M. Healthcare Disparities Add Insult to Spinal Cord Injury. Neurology. Clinical practice. 2021 Apr 1; DOI: https://doi.org/10.1212/CPJ.0000000000001095.


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

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