Telephone monitoring and support after discharge from residential PTSD treatment: a randomized controlled trial.

OBJECTIVE: This study assessed whether adding a telephone care management protocol to usual aftercare improved the outcomes of veterans in the year after they were discharged from residential treatment for posttraumatic stress disorder (PTSD). METHODS: In a multisite randomized controlled trial, 837 veterans entering residential PTSD treatment were assigned to receive either standard outpatient aftercare (N=425) or standard aftercare plus biweekly telephone monitoring and support (N=412) for three months after discharge. Symptoms of PTSD and depression, violence, substance use, and quality of life were assessed by self-report questionnaires at intake, discharge, and four and 12 months postdischarge. Treatment utilization was determined from the Department of Veterans Affairs administrative data. RESULTS: Telephone case monitors reached 355 participants (86%) by phone at least once and provided an average of 4.5 of the six calls planned. Participants in the telephone care and treatment-as-usual groups showed similar outcomes on all clinical measures. Time to rehospitalization did not differ by condition. In contrast with prior studies reporting poor treatment attendance among veterans, participants in both telephone monitoring and treatment as usual completed a mental health visit an average of once every ten days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care. CONCLUSIONS: Telephone care management had little incremental value for patients who were already high utilizers of mental health services. Telephone care management could potentially be beneficial in settings where patients experience greater barriers to engaging with outpatient mental health care after discharge from inpatient treatment.

Which stoma works better for colonic dysmotility in the spinal cord injured patient?

BACKGROUND: The formation of an intestinal stoma is very effective in the treatment of colonic dysmotility associated with spinal cord injury (SCI). Little is known about the difference in the long-term outcome among left-sided colostomies, right-sided colostomies, and ileostomies in this patient population. METHODS: The records of 45 SCI patients with intestinal stomas at our institution were reviewed retrospectively. Operative details and preoperative colonic transit times (CTT) were recorded. Patients who were alive and available were interviewed using a questionnaire designed to assess the quality of life (QOL), health status, and time to bowel care before and after stoma formation. RESULTS: Between 1976 and 2002, 45 patients underwent a total of 48 intestinal stomas. A left-sided colostomy (LC) was formed in 21 patients, right-sided colostomy (RC) in 20, and ileostomy (IL) in 7. Three of the patients in the RC group ultimately underwent total abdominal colectomy and ileostomy. The indications for stoma formation and CTT were different in the three groups. Bloating, constipation, chronic abdominal pain, difficulty evacuation with prolonged CTT was the main indication in 95% of patients in the RC group, 43% of patients in the LC group, and 29% in the IL group. Management of complicated decubitus ulcers, perineal and pelvic wounds was the primary indication in 43% of patients in the LC group, 5% in the RC group, and none in the IL group. Preoperative total and right CTTs were longer in the RC group compared with the LC group: 127.5 versus 83.1 hours (P <0.05) and 53.7 versus 28.5 hours (P <0.05), respectively. Eighty-two percent of patients (37 of 45) were interviewed at a mean follow-up of 5.5 years after stoma formation. Most patients who were interviewed were satisfied with their stoma (RC, 88%; LC, 100%; IL, 83%) and the majority would have preferred to have the stoma earlier (RC, 63%; LC, 77%; and IL, 63%). The QOL index significantly improved in all groups (RC, 49 to 79, P <0.05; LC, 50 to 86, P <0.05; and IL, 60 to 82, P <0.05), as well as the health status index (RC, 58 to 83, P <0.05; LC, 63 to 92, P <0.05; IL, 61 to 88, P <0.05). The average daily time to bowel care was significantly shortened in all groups (RC, 102 to 11 minutes, P <0.05; LC, 123 to 18 minutes, P <0.05; and IL, 73 to 13 minutes, P <0.05.). CONCLUSIONS: Regardless of the type of stoma, most patients had functional improvement postoperatively. Patients who underwent RC had longer CTT and more chronic symptoms related to colonic dysmotility, reflecting the preoperative selection bias. The successful outcome noted in all groups suggests that preoperative symptoms and CTT studies may have been helpful in optimal choice of stoma site selection.

The effects of colostomy on the quality of life in patients with spinal cord injury: a retrospective analysis.

PURPOSE: The purpose of this study was to evaluate the effects of colostomy on the quality of life (QOL) in patients with spinal cord injury (SCI) by designing a questionnaire that used self-reported data and correlating these data with the clinical information obtained from patients' medical records. MATERIALS AND METHODS: A comprehensive QOL questionnaire was designed to specifically address the following 5 domains: physical health, psychosocial adjustment, body image, self-efficacy, and recreation/leisure. This questionnaire was completed during a telephone or an in-person interview. The subjective data derived from the questionnaire were correlated with objective medical information obtained from a review of medical records. RESULTS: The QOL improved significantly (t = 9.1 28, P < .0001) after colostomy. All 27 (100%) patients were "satisfied," and 16 (59%) of them were "very satisfied" with colostomy. Nineteen (70%) patients would have preferred to have the colostomy done earlier, and only 3 (11%) patients wished it reversed. Colostomy reduced the number of hospitalizations caused by chronic bowel dysfunction by 70.4%. After colostomy, the average amount of time spent on bowel care was reduced from 117.0 min/day to 12.8 min/day (t = 7.964, P < .0001). All patients stated that colostomy simplified bowel care routine and increased independence. Significant improvements were recorded in the areas of physical health, psychosocial adjustment, and self-efficacy. Stoma prolapse and wound dehiscence were the most common complications of stomal surgery. When compared with medical data, patients were able to reliably recall average time with bowel problems (r = .881, P < .0001) and stomal surgery complications (r = .810, P < .0001). CONCLUSION: Colostomy is a safe and effective treatment for chronic bowel dysfunction in patients with spinal cord injury. It is well accepted by the patients and significantly improves QOL and bowel management procedures. Correlation analysis indicates that subjective patient-reported data are consistent with objective data obtained from the medical records.