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

描述（由申请人提供）： 该提案的目标是了解阿富汗和伊拉克退伍军人（持久自由行动/伊拉克自由/新黎明; OEF/OIF）战争中多发性创伤（包括血管肢体损伤）的长期结果和当前护理过程，长期目标是确定该人群的最佳实践。OEF/OIF退伍军人中肢体受伤的人数很多，他们的长期、复杂的护理要求对VA构成了重大挑战。战斗相关的血管损伤在该队列中占12%，比以前的战争高5倍，肢体损伤占伤亡人数的50-60%。医疗和外科创伤护理的改善，包括最初的手术室保肢方法（IILS），提高了生存率和减少了截肢，但是，长期的结果，如发病率，功能下降，并使用当前的护理过程中晚期截肢的风险尚未研究。建立了联合战区创伤登记数据库（JTTR），以获取有关OEF/OIF损伤人口统计学，机制和管理的信息，从现场首次评估到撤离和返回美国。我们的国防部（DoD）合作者已经开始探索血管损伤患者的结局，并报告说，在有限的患者样本中，大约86%的初始血管修复患者在损伤后5年内没有截肢。这一时期之后的结果，以及更大的退伍军人群体，尚未研究;目前护理过程的长期结果尚不清楚。 目前对创伤性血管修复患者的长期随访是基于治疗外周血管疾病（PVD;例如，抗血小板/他汀类药物治疗，每年一次的多普勒超声检查）。创伤性血管损伤修复没有最佳实践，因此临床医生对PVD患者的治疗方法如何影响这些受伤战士的长期结局几乎没有指导。此外，获得护理和护理的地理模式与PVD患者血管手术结局的差异相关。人们担心，由于创伤性损伤（适用PVD护理标准）进行血管修复后的结果也可能受到缺乏必要的专业知识来监测并发症的影响，但地理空间统计技术尚未扩展到创伤后血管修复患者的研究。为了解决这一知识缺口，我们提供了一个具有血管和骨科损伤、康复医学、流行病学和卫生服务研究专业知识的VA-DoD团队，通过解决以下目标，进行一项将护理过程与长期结果联系起来的研究：1）比较患者的损伤、人口统计学和地理空间特征与初始手术室保肢 （IILS），并确定晚期血管手术相关的肢体并发症和医疗保健利用， 接受VA与非VA护理的退伍军人，2）描述血管修复个体接受的预防性服务和相关结局，3）描述创伤性血管肢体损伤退伍军人患者报告的功能结局。 我们的VA-DoD团队和在圣安东尼奥的存在使我们能够识别肢体血管修复的服务成员/退伍军人，以确定长期护理和结果。本研究将提供关于OEF/ OIF退伍军人的当前护理过程的关键信息，这些退伍军人患有多发性创伤/血管损伤，有持续发病和晚期截肢的风险。这项研究的结果将是第一步，为临床医生在退伍军人事务部和军事设置，以产生基于证据的治疗和护理方法，这些伤害。它将确定需要物理治疗和血管专科护理或远程医疗选项的领域，以便更好地规划，资源利用和改善DoD到VA的护理过渡。

DESCRIPTION (provided by applicant): 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 repai 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.