Background: Access to necessary specialty care is a VA priority and a major barrier for rural veterans. Barriers to specialist care include geography, time, clinical culture, financial issues, and specialist availability. Chronic lower limb wounds are a complex problem and a leading cause of disability. These wounds impact overall disease burden, quality of life, ability to perform activities of daily living, and health care costs for thousands of veterans. Given the intensity and complexity of outpatient medical management required to heal chronic wounds and prevent subsequent wounds from occurring, the issue of access to care is of paramount importance in rural areas. There are no studies on access to care for these veterans. Project Aims:
Aim 1 : Identify and characterize an urban cohort and a rural cohort of VISN 20 veterans with at least one complex chronic lower limb wound in FY 2007.
Aim 2 : Compare findings from a medical record review in a random sample of rural and urban veterans identified in Aim 1 to determine: (a) if the veteran received evidence-based good wound care; (b) if the care was organized; (c) if the care was coordinated, and (d) the clinical outcomes. Secondary Aim: Compare amputation rates between the rural and urban veterans. Project Methods:
Aim 1 : We will identify a cohort of unique veterans with chronic lower limb wounds at each primary care site in VISN 20 using Austin data repository and the Consumer Health Information and Performance Set (CHIPS) database supplemented with VA Fee-Basis data. In order to improve the reliability of extracted administrative data we will: (1) conduct a confirmatory medical record review of veterans identified as having chronic wounds in a reliable clinic log maintained by an established organized wound care program at the rural Walla Walla VA center; (2) identify an optimum combination of chronic wound-relevant ICD-9 and CPT codes, that when applied to administrative data, yield an accurate reflection of clinic log data; (3) apply the best combination of codes to all VISN 20 administrative data; (4) validate the data extraction by review of a random sample of medical records from each primary care site; and (5) develop a timeline for care of each veteran's first incident chronic ulcer in FY 2007, describing medical complexity, access to care, time to healing, complications, and amputations.
Aim 2 : We will survey a retrospective cohort of wound care providers at each VISN 20 facility operational in FY '07 by video conference adapting instruments used in a prior VA survey, to ascertain whether a 'high' or 'low' level of organized wound care was available mid-year FY '07. Cox proportional hazards will be used to account for competing risks to model time to healing, proportion healed, outcomes, and amputation rates. Anticipated Impact: The results of this study will be the foundation for future interventions designed to improve access to evidence-based, organized, coordinated care for rural veterans with chronic lower limb wounds.
Access to time-critical specialty wound care is a VA priority and a major barrier for rural veterans. Chronic lower limb wounds are a complex problem and a leading cause of disability and limb loss. They impact disease burden, quality of life, and health care costs for thousands of veterans. VA data indicates 52% of lower limb wounds occur in veterans receiving care at primary and secondary care facilities and CBOC's. Given the intensity and complexity of outpatient medical management required to heal chronic wounds and prevent subsequent wounds from occurring, we will assess good wound care provided to veterans, the degree to which the care is organized and coordinated particularly in rural areas. There is no previous research on access to care for these patients.
