Early Advanced Therapy for Diabetic Foot Ulcers in High Amputation Risk Veterans: A Cohort Study.

Veterans with diabetic foot ulcers (DFUs) represent the highest percentage of lower extremity amputations (LEAs) within the Veterans Affairs (VA) population. Many veterans have additional risk factors for amputation. Few studies focus on advanced therapies for this population. This study explores the impact of early application of dehydrated human amniotic membrane allograft (DAMA) with comprehensive care on preventing amputation. This prospective, single-center cohort study (ClinicalTrials.gov Identifier NCT02632929) was conducted through Boise VA Medical Center. Patients with DFUs were objectively stratified for LEA risk. Those with moderate to high amputation risk could participate. Participants received comprehensive care and weekly application of DAMA. Primary endpoint was avoidance of major LEA. Secondary endpoint was wound epithelialization. Monitoring continued 4 months. Between July 2015 and March 2017, 20 patients (mean age 67.2 years) with 24 DFU classified as moderate (12 wounds) to high risk (12 wounds) for amputation were enrolled. Wound volumes ranged from 0.072 cm3 to 56.4 cm3. Risk factors included neuropathy (20 patients), osteomyelitis (16 wounds), exposed tendon/ligament/bone (19 wounds), Charcot (5 patients), and peripheral arterial disease (13 wounds). All subjects avoided amputation within the study period, all 24 wounds achieved re-epithelialization within 4 to 33 weeks; mean healing time 13.2 weeks. Cost for the DAMA tissue ranged from $750 to $38 150. Estimated cost for LEA ranges from $30 000 to $50 000. No treatment-related adverse events during the study period were reported. The results suggest that early and frequent application of DAMA with comprehensive care may help prevent amputation. Additional research will help inform third-party payors and clinicians.

Veterans' Voice Through the Lens of Their Medical Records: What It Reveals About Congestive Heart Failure Readmissions.

PURPOSE OF STUDY: The medical record is a sea of information that can reveal what patients are trying to tell us about their health condition. It can reveal hints and trends as to why veterans with congestive heart failure (CHF) are being readmitted within 30 days after hospital discharge. These hints and trends lead caregivers to key contributing variables to veterans' readmission. Furthermore, these variables can be used to predict patient outcomes such as readmission and even prognosis. This article looks at readmissions for CHF from documentation within the medical record to see what was driving the 30-day readmissions. Second, it examines whether the driving forces can be used to predict a veteran's increased risk for readmission or other poor prognosis. PRIMARY PRACTICE SETTING(S): The study was conducted at a rural 84-bed Veterans Health Administration hospital in the Western United States. METHODOLOGY AND SAMPLE: A retrospective screen was performed on 1,279 veterans' admissions of which 217 were identified as having CHF as a primary or secondary diagnosis on admission. The descriptive statistics, odds ratio (OR) and multivariate logistic regression were used to examine the data. The multivariate logistic regression equation was p = 1/1 + e, which can be found in the biostatistics textbook by . developed and validated the equation and used it to screen for undiagnosed diabetic patients. The equation was refined by . The variables selected for this study were based on a literature review of 30 articles. RESULTS: The probability and OR for 30-day readmissions for all ages increased as the age increased. The ORs for 30-day readmissions for the variables selected were as follows: brain natriuretic peptide 6.21 (95% CI [0.36, 108.24]), ejection fraction 1.298 (95% CI [0.68, 2.49]), hypertension 1.795 (95% CI [0.83, 3.85]), comorbid conditions 1.02 (95% CI [0.04, 25.02]), Stage III and below were protective, Stage IV 2.057 (95% CI [0.63, 9.32]), lack of discharge education 0.446 (95% CI [0.19, 6.45]). The impact of these variables on veterans with more than 3 readmissions (N = 66) was examined. In 32% of these admissions, there was insufficient data to compare the values of the variables between readmissions. In almost 26% (N = 17) of the cases as the number of variables increased, the time between admissions decreased. In 23% of the cases (N = 15), the values did not change; of these, 14 died and the one who survived had assistance with his care in the form of home health and telehealth. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Use of this evidence-based tool will help case managers to strategically plan care and prioritize interventions to impact the major variables and risk factors that are impacting veterans' health.

Hearing the Veteran's Voice in Congestive Heart Failure Readmissions.

PURPOSE/OBJECTIVE: Our purpose was to examine congestive heart failure (CHF) readmissions from the veterans' perspective. The use of health care provider interventions, such as standardized education materials, home telehealth, and a CHF clinic, was able to reduce readmissions rates from 35% to 23%. Our objective was to use input from the veterans to fine-tune our efforts and achieve readmission rates for patients with CHF below the national average of 21%. We wanted to identify factors that result in CHF readmissions, including disease education, self-care management, and barriers to self-care. This study was directed toward answering two questions: 1. What is the veteran's explanation for readmission? 2. According to the veteran, what are the barriers to following their treatment regimen? PRIMARY PRACTICE SETTING: It was a rural 84-bed Veterans Health Administration hospital in the Western United States. FINDINGS: Before this study, our efforts to reduce CHF readmissions were one-sided, all from the health care professionals' viewpoint. We wanted to hear what the veteran had to say; so, we interviewed 25 veterans. Four veterans were excluded due to issues with their consents. Ninety percent (n = 19/21) responded that they knew their CHF was worse by a change in their breathing (shortness of breath). They identified 48 signs/symptoms that indicated worsening CHF. Weight gain was noted as an indication of worsening CHF symptoms (n = 6/48) in 12.5% of the responses. Twenty-five percent (n = 12/48) of the veterans stated they recognized the early symptoms of worsening CHF. Thirty-eight percent (n = 8/21) of the veterans stated they had early symptoms of worsening CHF, but only two of them contacted their doctor. It is interesting to note that only 29% (n = 6/21) of the veterans recognized weight gain as a sign of worsening CHF and all of these veterans listed other symptoms (such as shortness of breath) along with weight gain. Weighing on a daily basis was practiced by only 30% of the group (n = 7/21); all but two of the veterans had no problems with weighing themselves. More than 71% of the veterans responded that they had no problems following their diet or taking their medications. More than half of the veterans did not need help with meals, transportation, or daily grooming/dressing/toileting. CONCLUSIONS: We were concerned about the evident delays in seeking medical care for worsening CHF. All veterans who did need help with the activities of daily living, medications, or diet had their needs met through their support systems. They did not perceive any barriers to seeking care. However, there remain many unanswered questions. Does the patient understand their discharge education and know how to use this information from daily weights or recognition of early symptoms, to indicate their need for urgent and emergency medical interventions? Or is it a problem that the education is not sufficient? Is it a question of the burden of care from multiple comorbid conditions or of taking too many medications? Do social issues drive readmissions? These questions are further explored in a second study, which is in the data analysis stage. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: There are three key findings from our study. 1. Veterans think in terms of symptoms that increase the impact of CHF on their life. 2. The relationship between daily weight and controlling CHF is not clear to veterans. 3. Hospital discharge instructions should clearly associate symptoms that are associated with worsening CHF.

The emerging role of telemedicine in diagnosing and treating sleep disorders.

Over one-third of adults are at risk of developing sleep disorders. Telemedicine is emerging as an effective tool in sleep medicine by allowing people to undergo sleep studies without overnight hospital stays (e.g. monitoring at home). Telemedicine has the potential to overcome several obstacles in the diagnosis and treatment of sleep disorders by offering increased access to sleep specialists, enhancing health-care support for patients in their homes and providing cost-effective professional education. The initial costs for telemedicine equipment and training are not insignificant; however, the benefits may outweigh the expense over time. However, recapturing the initial costs cannot be assumed.