VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration

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The goal of this proposal is to understand the long-term outcomes and current processes of care for Veterans of Afghanistan and Iraq (Operations Enduring Freedom/ Iraqi Freedom/New Dawn; OEF/OIF) wars with polytrauma including vascular limb injuries, with a long-term goal of identifying best practices for this population. The high number of limb injuries among OEF/OIF veterans and their long- term, complex care requirements pose a significant challenge to the VA. Combat-related vascular injuries are present in 12% of this cohort, a rate 5 times higher than in prior wars, and extremity injuries comprise 50-60% of casualties. Improvements in medical and surgical trauma care, including initial in-theatre limb salvage approaches (IILS) have resulted in improved survival and fewer amputations, however, the long-term outcomes such as morbidity, functional decline, and risk for late amputation of salvaged limbs using current process of care have not been studied. The Joint Theater Trauma Registry database (JTTR) was established to capture information on OEF/OIF injury demographics, mechanisms and management, from first assessment in the field through evacuation and return stateside. Our Department of Defense (DoD) collaborators have begun to explore outcomes for individuals with vascular injury and report that in a limited sample of patients, approximately 86% of those with initial vascular repair remain free of amputation 5 years post-injury. The outcomes after this period, and for the larger group of Veterans, have not been studied; long-term outcomes of the current process of care are not known. Current long-term follow-up for patients with traumatic vascular repair is based on best-practices for treatment of patients with peripheral vascular disease (PVD; e.g., antiplatelet/ statin therapy, annual duplex ultrasound). No best practices exist for traumatic vascular injury repair, so clinicians have little guidance about how treatment approaches for patients with PVD affect long-term outcomes in these wounded warriors. Moreover, access to care and geographic patterning of care have been associated with variation in outcomes for vascular procedures in patients with PVD. There is concern that outcomes after vascular repairs due to traumatic injuries (applying PVD standards of care) may also be affected by lack of access to the necessary expertise to monitor complications, but geospatial statistical techniques have not been extended to the study of patients with post-traumatic vascular repairs. To address this knowledge gap, we offer a VA-DoD team with expertise in vascular and orthopedic injuries, rehabilitation medicine, epidemiology, and health services research to conduct a study linking processes of care to long-term outcomes by addressing the following Aims: 1) Compare injury, demographic and geospatial characteristics of patients with initial in-theatre limb salvage (IILS) and identify late vascular surgery related limb complications and health care utilization in Veterans receiving VA vs. non-VA care, 2) Characterize the preventive services received by individuals with vascular repair and related outcomes, and 3) Describe patient-reported functional outcomes in Veterans with traumatic vascular limb injuries. Our VA-DoD team and presence in San Antonio uniquely position us to identify Service Members/Veterans with extremity vascular repairs to determine long-term care and outcomes. This study will provide key information about the current process of care for OEF/ OIF Veterans with polytrauma/vascular injuries at risk for persistent morbidity and late amputation. The results of this study will be the first step for clinicians in VA and military settings to generate evidence-based treatment and care approaches to these injuries. It will identify areas where physiatry and vascular specialty care or telehealth options are needed allowing for better planning, resource utilization, and improved DoD-to-VA care transitions.