Healthcare Utilization and Cost

Veterans Veterans Screened Screened and Assessed Assessed 

Traumatic Brain Injury

Kevin T. Stroupe, Ph.D

Center for Management of Complex Chronic Care

Hines VA Hospital

Program in Health Services Research

Department of Medicine

Loyola University Health System

June 27, 2012

VETERANS HEALTH ADMINISTRATION
Acknowledgements

Bridget M. Smith, Ph.DTimothy P. Hogan, Ph.DJ ti us n R. St. A dn re, MATheresa Pape, DrPH, MAMonica L. Steiner Steiner, MDEric Proescher, Psy.DZhiping Huo, MSCharlesnika T. Evans MPH, Ph.DFunding: Funding: VA HSRD SDR 08‐409: Evaluation Evaluation of TBI Scre

Scre

Processes and Healthcare Utilization (PI: B. Smith)

The views expressed ar

VETERANS HEALTH ADMINISTRATION

necessarily reflect the p

of Veterans Affairs or th
Background: Background: Mild Traumatic Traumatic Brain Inju

• 15% to 20% of Services Members in the Afghanista

(Operation Enduring Freedom [OEF]) and Iraq (Ope

Freedom Freedom [OIF]) conflicts conflicts have had mild traumatic traumatic b

(TBI)

• Mild TBI can manifest manifest as affective affective, somatic somatic, and co

co

symptoms including

– Headaches

– Problems with sleep– Balance and/or Memory

– Irritability– Sensitivity to light

VETERANS HEALTH ADMINISTRATION
Background: Background: Screening Screening of TBI

• VA implemented a national clinical reminder (CR) i

screen for TBI

• Veterans who screen positive are referred for a

comprehensive comprehensive TBI evaluation evaluation (CTBIE) (CTBIE)

• TBI diagnosis diagnosis is made after completion completion of CTBIEVETERANS HEALTH ADMINISTRATION
Objectives

• To identify healthcare utilization and cost patterns 

Veterans following screening for TBI

• To determine the association of patient characteris

healthcare healthcare utilization utilization and costs of OEF/OIF OEF/OIF Veteran

Veteran

screening for TBI

VETERANS HEALTH ADMINISTRATION
Study Design

• We examined healthcare utilization and costs over 

month period following an index date

• Index date

– For Veterans wi ht TBI screen: Date of TBI screen– For Veterans without TBI screen: Date of first VA

healthcare healthcare utilization utilization after separation separation from the 

and after April 14, 2007

VETERANS HEALTH ADMINISTRATION
–

Study Design (Cont.)

• All Veterans were categorized into TBI screening gr

whether they had:

– No TBI screen

– Negative Screen

Positive Screen

• Among Veterans Veterans with positive positive TBI screen who rece

rece

CTBIE, we categorized Veterans into CTBIE result g

– Negative Negative comprehensive comprehensive TBI evaluation evaluation (CTBIE) (CTBIE)– Positive comprehensive TBI evaluation (CTBIE)

VETERANS HEALTH ADMINISTRATION
Methods: Sample

• OEF/OIF Veterans were included if:

– Member of the VA OEF/OIF OEF/OIF roster

– Military service separation date was after Septembe

and before September 30, 2008

– Had a VA inpatient or outpatient visit between Apri

and September 30, 2008

– Indicated Indicated “yes” on the TBI screen that they had bee

in Afghanistan and/or Iraq

• Final sample d i er ved from this national popul i at on 

170,681 OEF/OIF Veterans

VETERANS HEALTH ADMINISTRATION
Methods: Methods: Data Sources Sources

• OEF/OIF Roster

– To identify subjects– Demographic data

• VA National TBI Health Factors database

– To create the index date for each Veteran

• Comprehensive TBI Evaluation database

• VA Medical Inpatient and Outpatient Datasets

• VA Decision Support System (DSS) National Data Ext

• VA Fee Basis Databases

VETERANS HEALTH ADMINISTRATION
M th e ods: Measures of H lth ea care Utilization 

• Outpatient utilization and cost categorizes include

clinic stop codes in DSS NDEs) :

– Primary care

– Rehabilitation care

– Polytrauma Polytrauma care

– Mental health care

– Other specialty care– Non‐VA outpatient (from Fee Basis files)

• We assessed costs on

– Day of index visit

– Day of comprehensive TBI evaluation (CTBIE)

VETERANS HEALTH ADMINISTRATION
Methods: Measures of Healthcare Utilization 

(Cont.)

• Outpatient pharmacy utilization and costs were fr

NDEs

• Inpatient utilization and cost categories included (b

bed section):

– Short‐term medical/surgical medical/surgical

– Spinal cord injury (SCI)

– Psychiatric– Rehabilitation– Intensive Care Unit

– Long‐term care– Non‐VA care financed by VA (from the VA Fee Basis 

VETERANS HEALTH ADMINISTRATION
Methods: Measures of Healthcare Utilization 

(Cont.)

• Total costs per patient during 12 months following 

included

– Total outpatient

– Total outpatient pharmacy

– Total inpatient

• All costs were adjusted to 2008 dollars using Consu

Index

VETERANS HEALTH ADMINISTRATION
Methods: Analyses

• We compared the 3 TBI screening groups and 2

comprehensive TBI evaluation result groups

– Chi‐Square: To compare Veteran characteristics

– ANOVA : To compare unadjusted utilization and cos

– Logistic regression: To compare hospitalization cont

patient characteristics

– Negative Binomial Models: To compare outpatient 

controlling for patient characteristics

– Generalized Generalized linear models with gamma distribution distribution 

function: To compare total costs

VETERANS HEALTH ADMINISTRATION
Sample Description: Description: By TBI Screening Screening Gr

• 170,681 Veterans met inclusion criteria:

– 14,266 (8%) had no TBI screen– 124,335 (73%) screened negative

– 32,080 (19%) screened positive

VETERANS HEALTH ADMINISTRATION
Patient Characteristics: By TBI Screening G

AGECharacteristic No TBI Screen Screened Negative ScGENDER: male 86.9% 85.9% 

Under 25 19.4% 20.0% 

25‐29 35.8% 31.3% 

30‐34 13.5% 12.8% 35+ 31.3% 36.0% 

MARRIED MARRIED 43.7% 46.8% RACE/ETHNICITY

White 68.2% 70.5% Black 16.7% 17.0% Hispanic Hispanic 12.3% 11.7% 

VETERANS HEALTH ADMINISTRATION
Patient Patient Characteristics Characteristics : By TBI Screening Screening G

Characteristic No TBI

Screen

Screened

Negative

EDUCATION

Some College 9.8% 10.8% 

College 7.0% 8.3% 

Beyond College College 2 1%. 2 4%. 

SERVICE CONNECTEDDISABILITY

33.8% 35.5% 

DISABILITY

High School/GED or less 81.1% 78.5% 

Some College 9 8% 10 8% 

VETERANS HEALTH ADMINISTRATION
VETERANS HEALTH ADMINISTRATION

Patient Patient Characteristics Characteristics : By TBI Screening Screening G

Characteristic No TBI

Screen

Screened

Negative

Anxiety Disorder 5.8 % 5.7% 

Adjustment Disorder 5.5% 5.2% 

Substance Substance Use Disorder Disorder 5 4%. 4 6%. 

Psychosexual Disorder 0.9% 0.9% 

Psychoses Psychoses 0 7%. 0 6%. 

Post Traumatic Stress

Disorder (PTSD)

15.4% 14.2% 

Disorder (PTSD)

Depression 11.6% 11.7% 

COMORBIDITIES

Anxiety Disorder 5 8 % 5 7% 
Patient Characteristics

VETERANS HEALTH ADMINISTRATION

: By TBI Screening Screening G

Characteristic No TBI

Screen

Screened

Negative

LOST CONSCIOUSNESS

Did Not Lose Consciousness 0% 2.3% 

Unknown 100% 96.1% 

EVACUATED EVACUATED FROM THEATER THEATER 0% 0 9%. ETIOLOGY

Bullet 0% 0 2%. 

Fall 0% 1.1% 

Vehicular Vehicular Accident Accident 0% 1 1%. 

Blast 0% 3.5% 

Did Lose Consciousness 0% 1.6% 

Did Not Lose Consciousness 0% 2 3% 
Healthcare Outpatient Utilizati

Months Following Following Index Date b

Screening Groups (Unadjust

VisitsOutpatient

For each type of outpatient outpatient visits: visits: P < 0.001 for comparison comparison of screening screening groups

VETERANS HEALTH ADMINISTRATION
Results: Utilization By TBI Screening Gro

(Unadjusted)

Healthcare Utilization No TBI Screen Screened

Negative

VA OUTPATIENT OUTPATIENT PHARMACY PHARMACY 7 0. 14.1 

Acute Care Days 0.2 0.4 

Rehabilitation Days 0.02 0.01 

Spinal Cord Injury (SCI) Days 0.01 0.02 

Mental Health Days 0.2 0.4 

Intensive Care Unit (ICU) Days 0.01 0.01 

Long‐Term Care Days 0 02 . 0 03 . 

Other Non‐Acute Care Days 0.1 0.3 

Non‐VA Days 0.05 0.06 

INPATIENT ADMISSIONS

Acute Care Days 0.2 0.4 

VETERANS HEALTH ADMINISTRATION
Healthcare Healthcare Costs 12 Months Following Following Index Da

Screening Groups (Unadjusted)

For each type of cost: P < 0.001 for comparison of screening groups

VETERANS HEALTH ADMINISTRATION
VETERANS HEALTH ADMINISTRATION

Results: Costs 12 Months after Index Date 

Screening Groups (Unadjusted)

INDEX EVALUATION $349 $404 COMPREHENSIVE TBI EVALUATION 0 $27 

Healthcare Cost No TBI Screen Screened

Negative

OUTPATIENT OUTPATIENT COSTS, TOTAL $2,732 $4,444 COMPREHENSIVE TBI EVALUATION 0 $27 OTHER OUTPATIENT COSTS

Primary Care $448 $705 

Rehabilitation Costs $71 $144 

Polytrauma Costs $36 $71 

M t en al H lth ea Care $446 $834 

Specialty Care $603 $950 

Other Outpatient Outpatient Costs $616 $1,048 

Non‐VA Outpatient Costs $162 $263 
Results: Costs 12 Months after Index Date 

Screening Groups (Unadjusted)

Healthcare Cost No TBI Screen Screened

Negative

INPATIENT INPATIENT COSTS, TOTAL $450 $753 

Rehabilitation Costs $18 $12 

Spinal Cord Injury Costs $11 $15 

Mental Health Costs $97 $178 

Intensive Care Unit Costs $17 $22 

Long‐Term Care Costs $9 $16 

Non‐Acute Care Costs $51 $119 

Non‐VA Costs $75 $93 

HEALTHCARE COSTS, TOTAL $3,399 $5,544 

Acute Care Costs $174 $297 

Rehabilitation Costs $18 $12 

VETERANS HEALTH ADMINISTRATION
healthcare utilization and costs te

Results: Association between TBI screening gro

healthcare utilization and costs (Adjusted

• After adjusting for patient characteristics, there cont

associations between TBI screening group and health

and costs during the 12 months after the index date

• For Veterans who screened positive compared to Vet

TBI screening, there were:

– 1.7 times more primary care visits

– 1.7 times more rehabilitation visits

– 2.5 times more polytrauma visits

– 1.5 times more mental health visits

– 1 6. times more other specialty specialty care outpatient outpatient visits– Total healthcare costs were $4,550 higher

VETERANS HEALTH ADMINISTRATION
Results: Association of patient characterist

healthcare utilization and costs (Adjust

Characteristic Hospitalized

Odds Ratio

Primary

Care

Visits

IRR

Rehabilitation

Care

Visits

IRR

Polytrauma

Care

Visits

IRR

Mental

Health

Care

IRR

Sp

MALE 0.8 0.7 1.1 1.3 0.9 EVACUATION 1.1 1.1 1.2 1.2 1.0 FROM THEATERBLAST INJURY 1.3 1.1 1.3 1.5 1.2 COMORBIDITIES

Psychoses 3.2 1.2 0.9 1.0 1.8 

Substance Use 3.1 1.0 0.9 0.9 1.3 

Disorder

Depression 1.6 1.1 1.0 1.1 1.5 

PTSD 1 4. 1 1. 1 1. 1 2. 1 7. 

COMORBIDITIES

VETERANS HEALTH ADMINISTRATION
Sample Description: Description: By CTBIE Result Gro

• Among those who screened positive and received 

– 6,163 (46%) tested positive for TBI– 7,305 (54%) tested negative for TBI

VETERANS HEALTH ADMINISTRATION
VETERANS HEALTH ADMINISTRATION

Patient Patient Characteristics: Characteristics: By CTBIE Result G

Characteristic CTBIE‐Negative CTBGENDER: male 94.1% 

AGE

Under 25 23.1% 

25‐29 31.4% 

30‐34 13.2% 

35+ 32.3% 

MARRIED 48.4% 

RACE/ETHNICITY

White 73.3% 

Bl k ac 15.0% 

Hispanic 11.6% 
Patient Patient Characteristics: Characteristics: By CTBIE Result G

Characteristic CTBIE‐Negative CT

EDUCATION

Some College 9.6% 

College 5.2% 

Beyond College 1.3% 

SERVICE CONNECTED DISABILITY 41.3% 

High School/GED or less 83.9% 

Some College 9.6% 

VETERANS HEALTH ADMINISTRATION
Patient Patient Characteristics: Characteristics: By CTBIE Result G

Characteristic CTBIE‐Negative CT

COMORBIDITIES

Anxiety Disorder 7.2% 

Adjustment Disorder 6.8% 

Substance Use Disorder 7.7% 

Psychosexual Disorder 1.1% 

Psychoses 0.6% 

PTSD 26.6% 

Depression 15.7% 

VETERANS HEALTH ADMINISTRATION
Patient Patient Characteristics: Characteristics: By CTBIE Result G

Characteristic CTBIE‐Negative CT

LOST CONSCIOUSNESS

Did Lose Consciousness 18.2% 

Did Not Lose Consciousness 69.8% 

Unknown 11.9% 

EVACUATED FROM THEATER 11.5% 

ETIOLOGY

Bullet 4.3% 

Fall 25.6% 

Vehicular Accident 23.4% 

Blast 74.8% 

VETERANS HEALTH ADMINISTRATION
Healthcare Outpatient Utilization 12 Months Follo

Date by Comprehensive Comprehensive TBI Evaluation Evaluation Result 

(Unadjusted)

nt Visits Outpatie

For each type of outpatient outpatient visits: visits: P < 0.001 for comparison comparison of CTBIE result groups,

except for other specialty care (p = 0.32)

VETERANS HEALTH ADMINISTRATION
Results: Utilization By CTBIE Result Gro

(Unadjusted)

INPATIENT ADMISSIONS

Healthcare Utilization CTBIE‐Negative 

VA OUTPATIENT OUTPATIENT PHARMACY PHARMACY 20.7 

Acute Care Days 0.9 

Rehabilitation Days <0.01 

SCI Days 0.01 

Mental Health Days 0.9 

ICU Days 0.01 

Long‐Term Care Days 0 03 . 

Other Non‐Acute Care Days 0.7 

Non‐VA Days 0.04 

VETERANS HEALTH ADMINISTRATION
Healthcare Costs 12 Months Following Index D

Comprehensive TBI Evaluation Result Group (Un

For each type of cost: P < 0.001 for comparison comparison of CTBIE result groups, except for

pharmacy (P = 0.89)

VETERANS HEALTH ADMINISTRATION
$ 

Results: Costs 12 Months after Index Date 

Result Groups (Unadjusted)

Healthcare Cost CTBIE‐Negative 

OUTPATIENT COSTS, TOTAL $8,836 OTHER OUTPATIENT COSTSINDEX EVALUATION $460 COMPREHENSIVE TBI EVALUATION $709 OTHER OUTPATIENT COSTS

Primary Care $993 

Rehabilitation Costs $412 

Polytrauma Costs $912 

Mental Health Care $1,888 

Specialty Care $1,314 

Other Outpatient Costs $1,776 

Non‐VA Outpatient Outpatient Costs $370 

VETERANS HEALTH ADMINISTRATION
Results: Costs 12 Months after Index Date 

Result Groups (Unadjusted)

Healthcare Cost CTBIE‐Negative 

INPATIENT INPATIENT COSTS, TOTAL $1,386 

Rehabilitation Costs $4 

SCI Costs $4 

Mental Health Costs $424 

ICU Costs $30 

Long‐Term Care Costs $23 

Non‐Acute Care Costs $203 

Non‐VA Costs $73 

HEALTHCARE HEALTHCARE COSTS, TOTAL $10,772 

Acute Care Costs $626 

Rehabilitation Costs $4 

VETERANS HEALTH ADMINISTRATION
Results: Association between CTBIE result g

healthcare utilization and costs (Adjust

• There continued to be associations between CTBIE 

group and healthcare healthcare utilization utilization and costs during t

months after the index date, after adjusting for pa

characteristics

• For Veterans with a positive comprehensive TBI ev

– 1.1 times more rehabilitation visits

– 1.2 times more polytrauma visits– 1.04 times more mental health visits

– Total healthcare costs were $972 higher

VETERANS HEALTH ADMINISTRATION
Results: Association between other facto

healthcare utilization and costs (Adjust

• Other patient and facility characteristics associated wit

utilization and costs included

– Male

• 0.8 times fewer primary care visits

• 0.8 time fewer other specialty specialty care visits

• Total costs were $1,524 lower

– Being evacuated from the theater

• 1.1 times greater odds of hospitalization

• 1.1 times more primary care visits

• 1.1 times more rehabilitation rehabilitation visits

• 1.2 times more other specialty care visits

• Total costs were $1,482 higher

VETERANS HEALTH ADMINISTRATION
Results: Association betwe

comorbidities and healthca

utilization utilization and costs (Adjust

(Adjust

• Psychoses

– 2.1 times greater odds of hospitalization– $6,820 higher costs than Veterans without this cond

• Substance use disorder

– 3.0 times greater odds of hospitalization– $3,930 higher costs than Veterans without this cond

VETERANS HEALTH ADMINISTRATION
Summary

• Veterans with a positive TBI screen had

– Over 70% higher healthcare healthcare costs than Veterans Veterans who scr

scr

$9,618 (Screened Positive) vs. $5,544 (Screened Negativ

– Over 180% higher costs than Veterans with no TBI screen

$9,618 (Screened Positive) vs. $3,399 (No TBI Screening)

• Veterans Veterans who received received CTBIE and had a positive positive di

di

TBI had

– 14% higher total costs than for those without a TBI diagn

$12,310 (Positive TBI diagnosis) vs. $10,772 (Negative T

VETERANS HEALTH ADMINISTRATION
Summary

• Substantial portion of services used were for ment

care during 12 months following following index date

– Largest number of outpatient visits were to mental – Over 40% of inpatient days in VA facilities were for 

health care

– Veterans with blast TBI etiologies, psychoses and su

have significantly higher odds of hospitalization afte

date

VETERANS HEALTH ADMINISTRATION
Implications

• This study highlights the additional resources need 

provide care for Veterans with TBI relative to othe

– Over 20% of Veterans had positive TBI screen but ac

over 30% of total cost ($308 million) among Veteran

recei d ve the screening ($997 million )

– Average Average annual cost of Veterans Veterans with TBI confirmed confirmed 

CTBIE ($12,310) was more than twice the average c

users ($5,765)

VETERANS HEALTH ADMINISTRATION
Implications

• Given the prevalence of TBI in OEF/OIF Veterans, e

regarding the resources needed for Veterans scree

is crucial crucial for healthcare healthcare planning planning

• Substantial Substantial portion portion of care following following the index visit 

directly mental health related, particularly for patiscreened positive for TBI

• Results Results from TBI screening screening may assist in anticipatin

anticipatin

and type of healthcare services needed by OEF/OI

VETERANS HEALTH ADMINISTRATION
Limitations

• CTBIE was not universally available or fully utilized 

system

• Some Veterans may have had private insurance an

non‐VA care that was not captured captured in the VA Fee B

• The duration duration of repeat service service use was not examin

examin

12 months

VETERANS HEALTH ADMINISTRATION
Conclusions

• Over 12 months following their initial evaluation,

– Veterans with a positive result on the on the TBI sc

over 60% higher total costs than Veterans Veterans who scre

scre

negative and more than double total costs of Vetera

TBI screening

• Understanding healthcare utilization and cost patt

following TBI screening is important for policymake

address the on‐going and future healthcare needs 

returning OEF/OIF Veterans

VETERANS HEALTH ADMINISTRATION
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Questions?

VETERANS HEALTH ADMINISTRATION