DoD-VA Trauma Infection Research Collaboration

Abstract

Background: In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma.

Methods: As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined.

Results: Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time.

Conclusions: Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.

FIGURE 1.

Timeline of events leading to approval of collaboration with the Department of Veterans Affairs (VA) for the Trauma Infectious Disease Outcomes Study (TIDOS) protocol. ID—infectious disease; IRB—Institutional Review Board; USU—Uniformed Services University of the Health Sciences.

FIGURE 2.

Time to new infection related to trauma injury following initial trauma hospital discharge. Figure is reprinted with permission of Oxford Academic Press

FIGURE 3.

Kaplan–Meier survival plots (with 95% Hall–Wellner bands) of time to new infection following initial trauma hospital discharge. A, Plot stratified by injury severity score. Log-rank χ², 16.8 (P < 0.001); Wilcoxon χ², 16.2 (P = 0.001). B, Plot stratified by volume of blood transfusion within 24 hours of injury. Log-rank χ², 11.2 (P = 0.011); Wilcoxon χ², 7.4 (P = 0.060). C, Plot stratified by length of inpatient hospitalization. Log-rank χ², 18.7 (P < 0.001); Wilcoxon χ², 15.7 (P = 0.001). D, Plot stratified by number of inpatient infections. Log-rank χ², 21.8 (P < 0.001); Wilcoxon χ², 18.2 (P < 0.001). Figure is reprinted with permission of Oxford Academic Press.