Dr. Dawn M. Bravata Joins Stroke QUERI as Clinical Coordinator

Dr. Dawn M. Bravata joined the Stroke QUERI as the Clinical Coordinator in December 2006, when Dr. Linda Williams became the Research Coordinator. Dr. Dawn Bravata, an internist and stroke researcher, graduated from Yale University in 1989; and the University of California, San Diego School of Medicine in 1993. She trained as an intern, resident and Chief Resident at the Yale School of Medicine Primary Care Residency Program.

In 2000, Dr. Bravata graduated from the Yale Robert Wood Johnson Clinical Scholars Program, and joined the VA Connecticut Healthcare System at West Haven, where she practices Internal Medicine and serves as Director of the Multidisciplinary Stroke Program. She is an Associate Professor of Medicine at the Yale University School of Medicine.

Dr. Bravata conducts health services research in cerebrovascular disease. The fundamental goal of her research is to improve the quality of care for patients with cerebrovascular disease. She is interested in three topics within this larger domain: the effectiveness of therapeutic interventions for patients with acute ischemic stroke and transient ischemic attack (TIA), the quality of care received by patients with stroke and TIA, and the identification and treatment of medical co-morbidities in patients with cerebrovascular disease.

Florida Veterans Utilize a Variety of VA and Non-VA Services Post-Stroke

VHA is not the only source of care for its enrollees. This is particularly true for those enrollees who are also eligible for Medicare and/or Medicaid. However, our understanding about the VHA stroke patients who receive services within VHA and beyond is limited. In a recently completed, HSR&D-funded IIR study on VHA enrollees with acute stroke in Florida, Dr. Charlie Jia and his research team found that: (1) over 70% of the stroke patients relied on VHA and other health care programs (Medicare and Medicaid) for their post-stroke care; (2) user groups (VHA only, VHA, and Medicare, VHA and Medicaid, and all three systems) were demographically and clinically distinctive; (3) patients who had their initial inpatient stroke care under VHA received less rehabilitation services during their initial hospitalization and 12-month follow-up outpatient care than Medicare-initial inpatients; (4) many multiple systems users obtained their post-acute rehabilitation services from VHA outpatient clinics; (5) multiple-source users were more likely to be re-hospitalized for any cause and for recurrent stroke within the first 12 months post index as compared to the VHA-only users; (6) mortality outcomes depended on when the outcome was measured: If measured from the index admission date, there was no significant difference across the user groups occurred; if measured from the index discharge date, the VHA-only users were less likely to die within the first 12 months than users of the two dual groups. These findings may help improve VA clinicians’ understanding of their patients’ characteristics, continuum of care post-stroke, and the importance of considering dual or triple system usage when conducting program evaluations for healthcare systems with a high proportion of dual or triple enrollees.

Based upon the methodologies developed and findings from the Florida project, the research team is expanding to a national level study with a HSR&D newly funded project. The objectives of the national study are to: (1) refine the patients’ eligibility and utilization status for each healthcare program (VHA and Medicare); (2) describe and compare the demographic and clinical characteristics between the different user groups (VHA only, VHA-Medicare, and Medicare only); (3) compare 12-month pre-index and 12-month post-index stroke healthcare utilization between the different user groups as well as the patterns of health services dual use by the dual users, (4) predict the out-of-VA healthcare use, and (5) estimate longitudinal differences in post-index stroke mortality, re-hospitalization, fractures, and discharge to community at index hospitalization between the user groups and geographic regions.

For more information: Dr. Charlie Jia, 352-376-1611, ext. 4926.

Tele-Rehabilitation Expands Rehabilitation for Veterans with Stroke

Veterans who have suffered a stroke require long-term rehabilitation. However, the Stroke QUERI has found that a large number of acute stroke patients live more than 120 minutes from an inpatient rehabilitation unit (RBU), or they receive care at a facility without a RBU. Dr. Neale Chumbler, Dr. Barbara Lutz, located in the Gainesville, NF/SG Veterans Health System, and Dr. Helen Hoenig, a physician investigator, in the Durham VAMC, have researched tele-health and tele-rehabilitation approaches to address the veterans rehabilitation needs. In 2006, Drs. Chumbler and Lutz completed a QUERI locally initiated project (LIP) that initially tested the VA Care Coordination/Home Telehealth (CCHT) Program. They found that the program can provide a post-discharge link for the veterans and their caregivers with the VA that includes expert advice, and information on respite. In addition it may help the caregiver manage the patient’s stroke throughout the recovery process. An article on this project will appear in a special journal issue on post-discharge care for stroke: Lutz, B.J., Chumbler, N.R., and Roland, K., Care Coordination/Home-Telehealth for veterans with stroke and their caregivers: Addressing an unmet need, Topics in Stroke Rehabilitation, 2007 (February, in press).

The pilot information from the LIP has supported the development of a Phase II, two-arm, four-site randomized controlled trail. Drs. Chumbler and Hoenig are the PIs, and it is funded for three years beginning in early 2007. The purpose of this study is to examine a tele-rehabilitation (TR) intervention that uses tele-health technology to improve outcomes of stroke patients after discharge to home. They will be examining the effect of TR on physical functioning, disability, falls and patient satisfaction.

For more information: Dr. Neale Chumbler, 352-376-1611, ext. 4920.

Post-Stroke Swallowing Projects Start in 2006

In 2006, a VA Office of the Inspector General (OIG) published a report on the management of patients with feeding and swallowing problems in VA facilities. The report found significant variation in care and the need for improved dysphagia evaluation and management. Although the OIG report is not restricted to stroke, swallowing problems are a common problem after stroke. In response to the report, the Stroke QUERI is responding with two new initiatives on swallowing screenings. The first response is a RRP pilot implementation project in 2007 that will address the establishment of better initial screening of patients with acute stroke. The project will take place in Gainesville and Indianapolis VA facilities and provide the team with an opportunity to compare and contrast how the two sites handle the implementation of screening tools and processes. The second initiative for the Stroke QUERI is working with the Office of Quality and Performance (OQP) on the development of a Dysphagia Supporting Indicator to measure swallowing screenings completed on patients suffering a stroke. The anticipated beginning date for the indicator is FY 2008.

For more information: Dr. Neale Chumbler, 352-376-1611, ext. 4920.