Optimizing Management of Urinary Tract Infections in Patients with Neurogenic Bladder through Improved Knowledge of Provider Practice and Patient-reported Outcomes

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Project Summary/Abstract Chronic neurologic injuries and diseases such as spinal cord injury (SCI), multiple sclerosis (MS), and Parkinson's disease (PD) often cause chronic bladder dysfunction termed `neurogenic bladder' (NB). Over 400,000 people are estimated to be living with NB in the U.S. The VA provides a significant amount of services for these patient populations, due to its unique focus on coordinated, lifelong care for Veterans with complex, chronic disabling conditions. Urinary tract infections (UTIs) are common complications in patients with NB and can cause pyelonephritis, sepsis, kidney stones, and, rarely, death. UTI management is challenging because bacteria frequently colonize a neurogenic bladder without infection, a situation called “asymptomatic bacteriuria” (ASB). Furthermore, UTI symptoms are often atypical in patients with NB due to impaired bladder sensation. Antibiotic treatment of UTIs is critical, however routine treatment of ASB is not beneficial and may lead to harm. Despite this, many patients with NB due to SCI, MS, and PD are managed improperly with high rates of unnecessary and/or inappropriate antibiotic use. [Improper UTI management directly impacts patient rehabilitative health, functioning, and quality of life via the long-term and profound adverse consequences of antibiotic resistance and antibiotic overuse.] However, the association of UTI management with patient- reported rehabilitation outcomes has not been well-studied or clearly delineated. Support from the CDA2 will provide Dr. Fitzpatrick with the necessary foundation for a successful career as a VA [rehabilitation researcher focused on implementing interventions to improve Veteran rehabilitative health by optimizing infectious diseases management and antibiotic use in patients with NB due to complex, chronic neurologic injuries and diseases.] Appropriate UTI management and avoidance of unnecessary antibiotics is critical to ensure the delivery of high quality, safe care for these high-priority patients. This innovative project will study a cohort of patients with NB [due to SCI, MS, and PD] cared for at a range of VA hospitals of varying geographic locations and sizes. It aims to characterize variations in care provided for ASB and UTI and associate them with key provider and patient characteristics using a retrospective cohort study with electronic health record data. It further aims to use qualitative methods to assess patient knowledge, attitudes, beliefs, and expectations regarding ASB and UTI and measure UTI-related patient-reported rehabilitation outcomes. In this way, the project represents a critical step forward in developing a patient-centered approach to ASB and UTI management. Results from this project will be used to support Dr. Fitzpatrick's VA Merit Review application to develop a multimodal patient-centered intervention to [improve functional and patient-reported rehabilitation outcomes via improved ASB and UTI management in patients with NB.] The specific components of the intervention will be informed by data acquired in this project and targeted to key patients and care settings associated with high rates of inappropriate management. Results from this study will also inform future efforts to use electronic health record data to [develop computable phenotypes for ASB and UTI in patients with NB] which will aid future research and quality improvement projects related to improved ASB and UTI management. Therefore, completion of this CDA2 project is expected to provide the critical groundwork leading to successful interventions for ASB and UTI management that improve health, functioning, and quality of life of for Veterans with NB due to chronic neurologic injuries and diseases.