**Transcript of Cyberseminar**

**HERC Monthly Health Economics Seminar**

**Healthcare Utilization and Costs of Veterans Screened and Assessed for Traumatic Brain Injury**

**Kevin T. Stroupe, Ph.D.**

**June 27, 2012**

Robert Kerns:Thank you so much, it is a pleasure to welcome Kevin Stroupe for the presenture today. He got his PHD in 1998 in Economics, and then joined the VA the same year I did in 1999, so we have been sort of peers going through the program together. He is at the Hines VA and he is affiliated with three centers there, the HSR&D there, the QUERI Centers, and as well the CSP Program there, and has done some amazing research. One of the areas that he is getting into more and more is this area of traumatic brain injury and it is a very hot topic these days in VA, so I am very excited to have Kevin presenting his work today. Thanks Kevin.

Kevin Stroupe:Alright thanks Bob. Okay as mentioned, today I will be discussing some work that we have done looking at Health Care Utilization and Cost, Veterans screened and assessed for traumatic brain injury. First, I would like to acknowledge the co-authors and colleagues who have been involved in this study, and note that this study was funded by a VA HSR&D SDR, Evaluation of TBI screening processes and health care utilization that Bridget Smith was the principle investigator of. 

So first, some background about traumatic brain injury. Approximately 15% to 20% of Veterans from the Afghanistan and Iraq conflicts, also called Operation Enduring Freedom, OEF, and Operation Iraqi Freedom, OIF, have had mild traumatic brain injury. Mild TBI is a condition that can manifest as effective somatic and cognitive symptoms including such things as headaches, problems with sleep, balance and/or memory, irritability, sensitivity to light, and so on. While these symptoms usually resolve in a matter of hours, weeks or a few months, in some cases they may persist over longer durations and longer periods of time. 

So, because given the high prevalence of mild TBI within the OEF/OIF population, the VA implemented clinical reminder in 2007 to screen for TBI. Since Veterans may respond positively to the questions in the TBI screen, because of the presence of symptoms that may be related to other conditions, a positive screen does not necessarily indicate that the Veteran has a definitive diagnosis of TBI. So, Veterans who are screened positive for TBI on the clinical reminder screen are then referred for a comprehensive TBI evaluation and then a diagnosis of TBI is made after the completion of the comprehensive evaluation.

So for the VA to ensure that adequate resources are then available for the OEF/OIF Veterans with TBI, it is going to be important to understand what the healthcare utilization and the healthcare costs of these Veterans are following the TBI screen and following the comprehensive evaluation, when a definitive diagnosis then of TBI is made. So that is what we will be looking at today. In particular the two objectives of this particular study are first to identify the health care utilization and cost patterns of OEF/OIF Veterans following their screening for traumatic brain injury. And second, this was to determine the association of the patient’s characteristics with their health care utilization and cost following the screening for TBI. And as noted, these were two specific objectives of this particular study and the results that I am presenting today are part of a larger study looking at more issues around the TBI screen. 

So first, we turn to the issue of the overall study design that we will be presenting today, and we examine the health care utilization and cost over a 12 month period following an index date where the index date was defined for Veterans with the TBI screen as the date on which the TBI screening occurred. However for Veterans who did not receive the TBI screen, for example they may not have shown up for an appointment, they may have refused to take the screening and so on. For those Veterans and for the purpose of the study, the index date was defined as the date of their first VA health care utilization following separation from the military and after April 14, 2007. 

Additionally, all Veterans were categorized into TBI screening groups by whether they had no TBI screening, whether they had a negative result on the TBI screen or whether they had a positive result on the TBI screen. So we looked at three TBI screening categories. Then in addition, among the Veterans with a positive TBI screen who then received the comprehensive evaluation, we categorized Veterans into two groups, based on the comprehensive TBI evaluation result. Veterans who received either a negative comprehensive TBI evaluation, or Veterans who had a positive comprehensive TBI evaluation which therefore indicated that they had a confirmed diagnosis of TBI. 

Now it is important to note that for purposes of this study, that because the comprehensive evaluation was not available or widely used in the VA during the timeframe that we examined for this particular study, some Veterans in our sample who screened positive on the TBI screen, however did not receive a comprehensive TBI evaluation. So the results of the comprehensive evaluation were only available for a subset of the sample of Veterans in this study who screened positive for TBI. 

Next, we will look at how the sample itself was derived. We were looking at OEF/OIF Veterans who are included if, first, if they were members of the VA’s OEF/OIF roster which I will describe in more detail a little bit later. If their military service separation date was after September 11, 2001, but before September 30, 2008. Three if they had a VA inpatient or outpatient visit during April 14, 2007 to September 30, 2008, and if they indicated yes on the TBI screen that they had been deployed to Afghanistan and/or Iraq. That gave us a final sample then that we used for this study of over 170,000 OEF/OIF Veterans. So then throughout the presentation today, we will be looking at that group of Veterans and we will be describing them by first the three TBI screening groups or then later by the two comprehensive evaluation results groups.   

Okay, next I want to turn to the data sources for this particular study. We use the OEF/OIF Roster on the VA’s National TBI Health Factors database. The comprehensive TBI evaluation database, the VA medical staff’s inpatient and outpatient data sets, the VA decision support national data extract, and the VA fee basis data sets.

The VA’s National OEF/OIF Roster contains information on Veterans separated from OEF and OIF military service who have enrolled in VA health care. This roster is derived from the VA Health Eligibility Center enrollment file and from the Department of Defense, Defense Manpower Data Center, DMDC database. We use the OEF/OIF Roster to identify all the Veterans in our sample, and then to extract demographic data including their gender, race, ethnicity, marital status and education.  

Results from each Veterans TBI screen were abstracted from the VA National TBI Health Factors database. This database is managed by the VA office of patient care services and is derived from the VA’s electronic health record. Elements of the TBI screen that we extracted, included responses to the four item question set that is part of the, that is the TBI screen, the date that the TBI screen occurred and the date of the separation from the military. We use this information then from the VA National TBI Health Factors database to create that index date which I referred to earlier, which is the starting point then following – then we are looking at 12 months following that for the health care utilization and cost. 

The comprehensive TBI evaluation results for each Veteran were extracted from the comprehensive TBI evaluation database which is also managed by the VA’s Office of Patient Care Services. Additional clinical and demographic data for each Veteran were extracted from the VA medical staffs inpatient and outpatient data sets, including the date of birth, most frequently occurring zip code, and core morbidities. 

Health care utilization for the 12 months following the index date, were obtained from the VA’s Decision Support National Data extracts and in addition, we obtained information on the non-VA care that is financed from the VA, from the VA’s fee based data sets. 

Outpatient healthcare utilization and cost that we examined in the study, included primary care, rehabilitation care, polytrauma care, mental health care, other specialty care, and all of these were designed based on clinic stop codes in the VA DSS National Data Extracts. In addition, we looked at non-VA outpatient care from the fee basis files. We calculated then the number of outpatient encounters and costs that Veterans had for each type of care, and we also assessed the cost of the day on which the index visit occurred, as well as the cost on the day which the comprehensive TBI evaluation occurred. 

Veterans outpatient pharmacy utilization and the cost for pharmacy, was obtained from the DSS National Data Extracts for Pharmacy. Inpatient utilization and costs were categorized into multiple categories and based on time spent in a particular care unit based on the VA’s bed section. These included total number of days for short term medical surgical care, spinal cord injury care, psychiatric rehabilitation, and long term care. And in addition, we looked at the number of days and costs of care financed by the VA from the fee basis files. 

So in addition to looking at the amount of utilization across the different categories of care, we also examined the most frequently occurring inpatient admitting diagnoses that occurred for Veterans which we obtained from the VA’s medical staff inpatient data sets. 

So overall then for total cost, we examined the total cost of care per patient over the 12 months following the index visit based on the total outpatient cost which were the sum of the primary care rehabilitation polytrauma, mental health, other and so on. The total pharmacy, the total outpatient pharmacy and the total inpatient as well as the cost of care on the day of the index visit and the cost of care on the day of the comprehensive TBI evaluation, and we converted all costs to 2008 dollars based on the consumer price index. 

Next then we will turn to the analysis that we conducted for this particular study. As I noted earlier, we compared utilization and costs among the three TBI screening groups, the patients who had no screening, negative results on the TBI screen or a positive result and the two comprehensive TBI evaluation results groups. So either they had a positive result and a confirmed diagnosis of TBI or negative on the comprehensive evaluation. Veteran’s characteristics prior to the index date were compared using Chi-square tasks, we were looking mostly at proportions, unadjusted health care utilization and costs were compared between the three TBI screening groups and the two comprehensive evaluation groups using analysis of variance of ANOVA. To investigate the association of the TBI screening group and the comprehensive TBI evaluation results groups with health care utilization and cost, we used regression analysis, controlling them for other demographic, clinical, and other factors. 

Specifically we used logistic regression to examine the probability of hospital admission during the 12 month period following the index day. Also, because the number of outpatient visits during the 12 month period following the index date, were non negative integers we used a negative Binomial count models to allow for over disbursing of the data. And in both cases, we used hierarchical logistic and negative binomial models to adjust for correlation of patients within VA facilities. 

To examine the association of the three TBI screening groups and the two comprehensive evaluation groups regarding total health care costs during this 12 month period after controlling for the other factors, we used generalized linear models, GLM, where we used gamma distribution with a log link function based on a modified heart test and a Box-Cox test. And we estimated robust standard areas to accommodate the non independence within VA facilities. 

So that provides a summary of the overall methods that we used to examine the health care utilization and costs among our patients so next we will look at a sample description of the patients that were included in the study. So first, we will be examining health care utilization and cost among the three TBI screening groups. And then next we will turn to the health care utilization and cost between the two comprehensive TBI evaluation groups. So of the over 170,000 Veterans who met our inclusion criteria, approximately 14,000, or 8% of the sample, had no TBI screening and as I noted that could missed appointments, refusal to take the screening and so on. Over 124,000 or 73%, screened negative on the TBI screening and over 32,000 or 19% screened positive. 

So next, we will turn to an examination of patient characteristics between these TBI screening groups. Where throughout the presentation, the numbers that have been folded will indicate situations where the T value was significant at the point .05 level. So as we can see, Veterans who screen positive, a larger proportion were male, additionally and regards with age, a larger proportion of Veterans who screened positive were under 25 years of age, a slightly larger portion were married, and a larger portion of Veterans who screened positive were white relative to the other screening groups. However, we did not find a significant result regarding Hispanic ethnicity. 

Next, turning to level of education, we see that a larger proportion of patients who screened positive had a high school or less. And in addition, patients who screened positive, a larger proportion of those had a service connected disability relative to the Veterans who screened negative or who had no TBI screening. 

With regard to the comorbidities of the Veterans in our sample, we see that in general, Veterans who screen positive, a larger proportion had the various comorbidities that we examined. In particular, post traumatic stress disorder, PTSD, 30% of those that occurred among the patients who screened positive. Additionally a higher proportion with depression were among those who screened positive relative to those who screened negative or had no TBI screening. 

Then finally, with regard to patient characteristics, a larger proportion of patients who screen positive than did not screen positive, experienced a loss of consciousness, were evacuated from the military theater or had an injury etiology in particular, a blast injury. 

So next then, we will take a look at unadjusted health care utilization during the 12 months following the index day by the TBI screening groups. And as noted, this information is not adjusted for patient characteristics, we will look at some unadjusted results in a bit. 

Veterans who screen positive on the TBI screen, had more health care utilization during the 12 months following, then Veterans who screen negative or Veterans who did not have TBI screen. The Veterans who screened positive, averaged 7.2 mental health care visits, compared with 3.5 for Veterans who screened negative and 1.9 visits during that 12 month period for Veterans who did not have the TBI screen.

And moreover, we can see that there was a similar pattern across the other groups of outpatient care where Veterans who screen positive had a higher number of primary care visits, rehabilitation care, polytrauma care, and other specialty care. 

Next then we will turn to some other aspects of care, we see that Veterans who screen positive receive more medications from VA pharmacies than Veterans who screen negative or who had no screening. Where the numbers that we are presenting indicate the number of 30 day equivalent supplies of medications that were dispensed by VA pharmacies. So we see patients who screen positively had over 30 day equivalent dispensing the medication, compared with 14 and 7 for those with negative screening results or no screening results. 

As with the outpatient visit and the outpatient pharmacy, Veterans who screen positive had more acute medical surgical days as well as more mental health care days than Veterans who screen negative or Veterans who had no TBI screening. The most common inpatient diagnoses among all three TBI screening groups was for post traumatic stress disorder. And as we saw earlier, a larger portion of the patients had that condition. An admitting diagnoses of PTSD accounted for 32.7% of all admissions among Veterans who screen positive. That accounted for over 19% of admissions for Veterans who screened negative, and 10% of admissions for Veterans who had no TBI screening. This was followed by a diagnoses of alcohol dependence, which accounted for between 3.5% and 4% of admissions. 

Next then, looking at health care costs, we see that total health care costs per patient were nearly double for Veterans who screened positive over $9,600 compared to Veterans who screened negative. And over $5,500 and they were nearly three times of the cost of Veterans who did not have the TBI screening, whose total cost was $3,300. 

Outpatient costs per patient comprised approximately 90% of total health care costs. Among Veterans who screen positive, outpatient costs per patient were about $7,700 among the patients who screen negative. Among patients who screen positive the costs were about $7,700. Among patients who had a negative screen, the costs were about $4,400. And those with no screening had total outpatient costs of $2,700. And we see that a similar relation existed in a moment that existed between each category of outpatient care as well. 

Inpatient costs comprised approximately 14% of total healthcare costs, where $1,300 for patients who screen positive, about $750 for patients who screen negative, $450 for patients with no screening. And finally, outpatient pharmacy costs comprised 5% to 6% of total health care costs. 

So next then we will break down total outpatient costs into the various categories that I mentioned earlier on the primary rehabilitation, polytrauma, and so on. And for these various subcategories, outpatient care, we see that within each of these we saw a similar pattern where there were higher costs for patients who screen positive than patients who screen negative or patients who had no TBI screening. 

For patients inpatient care, Veterans who screen positive had more acute medical surgical days and more mental health care days than patients who screen negative or had no TBI screening. After adjusting for patient characteristics, there continue to be an association between the TBI screening group and the health care utilization costs during the 12 month following the index date. Among Veterans who screen positive, compared to Veterans with no TBI screening there were 1.7 times more primary care visits, 1.7 times more rehabilitation care, 1.2 times more poly trauma, 1.5 times more mental health care visits and so on. 

Total health care costs from our GLM analysis were $4,500 higher for Veterans who screen positive than for Veterans with no TBI screening. Health care utilization and cost were also higher for Veterans who screened negative compared to Veterans with no TBI screening. 

So in this table, we have presented the odds ratios for hospitalization from the logistic progression model. The incident rate ratios for outpatient utilization from our negative Binomial count models and the marginal effect of characteristics on total cost from our GLM analysis. 

So among the other patient characteristics that were associated with health care utilization and costs, we found that being male was associated with lower odds of hospitalization, fewer primary care outpatient visits and overall lower total costs. However among other characteristics, being evacuated from the theater was associated with greater odds of hospitalization, more primary care, more rehabilitation, poly trauma and other specialty care, and higher costs. 

Among the injury ideology’s we found that a blast injury had the greatest association with utilization and cause. A blast injury was associated with about 30% greater odds of hospitalization, about 1.25 times more rehabilitation visits, about 1.5 times more polytrauma visits, and $1,600 in higher costs over that 12 month period. Among the comorbidities that we examined. Psychosis and substance abuse disorder had the greatest association with costs followed by depression and PTSD. 

So, as I noted earlier, the first set of analysis that we examined were among the three TBI screening groups where we looked at patients who had no screening, patients who screened negative or patients who screened positive. Then next we are going to turn to the comparison of health care utilization and costs between Veterans who screen positive for TBI and then receive a comprehensive TBI evaluation. Among the Veterans who screen positive and receive the comprehensive evaluation, over 6,000 or 46% tested positive for TBI. And over 7,000 or 54% of our sample, then tested negative for TBI. And again, it should be noted that because the comprehensive TBI evaluation was not available or widely used across the system during the time frame that we studied, some of the Veterans in our sample who screened positive on the TBI screen, did not receive the comprehensive evaluation.

So among overall patient care characteristics of this subgroup of patients then who had the comprehensive evaluation, a larger portion of Veterans with the confirmed TBI with comprehensive evaluations were male, were under 25 years of age and were white, compared to the proportion among patients who had a negative result on the comprehensive evaluation.

A larger portion with the confirmed TBI, meaning they had a positive result from the comprehensive evaluation, also had high school education or less, and service connected disability. 

Among the comorbidities for this group, a larger portion, who had TBI confirmed through the comprehensive evaluation had post traumatic stress disorder, PTSD. Moreover, a larger portion of patients with a confirmed TBI, experienced the loss of consciousness and were evacuated from the theater. And among the injury ideology’s an especially large proportion of patients with TBI experienced a blast related injury. 

So next we turn to outpatient utilization during the 12 months following the index date by the comprehensive TBI evaluation result for this group of patients who both screened positive and who had the comprehensive TBI evaluation. Veterans with a positive result from the comprehensive TBI evaluation, had more outpatient utilization than during the 12 month period following the index date, than patients with a negative result. For example, patients with confirmed TBI had 8 1⁄2 mental health care visits compared with 7 1⁄2 for patients without a confirmed TBI. Veterans with a positive comprehensive TBI evaluation result had similar numbers of medication from VA pharmacies. However, Veterans with a positive comprehensive evaluation result, had more acute and mental health care days. And non VA health care days than patients with a negative result. As we saw earlier, the most frequently occurring inpatient diagnoses was PTSD accounting for 38% of admissions for patients with confirmed TBI, and 32% of the admissions for patients without TBI followed by alcohol dependence, which accounted for between 3.8% and 4.9% of the admitting diagnoses. 

Next then we turn to health care costs during the 12 month period following the index date, by the comprehensive evaluation group. Total inpatient and total outpatient costs were lower for Veterans who screen negative and did not have a confirmed TBI than for Veterans who did have a confirmed TBI. Outpatient costs, again the pattern was similar to the groups that we saw earlier. Outpatient costs comprised approximately 80% of the total health care costs during this time period, inpatient costs comprised of approximately 15% of total health care costs, and outpatient pharmacy comprised of approximately 5% of total health care costs. 

Veterans with confirmed TBI had similar costs for the date that occurred on their index evaluation as well as similar costs on the day during which the comprehensive evaluation occurred. However, patients with positive comprehensive TBI evaluation, had higher outpatient costs than Veterans with a negative result, on most of the categories of outpatient care. 

Additionally, patients with a confirmed TBI through the comprehensive evaluation had higher total inpatient costs about 2,000 versus 1,300 as well as higher acute care and mental health care. And non VA inpatient costs. And overall higher total costs than patients who had a negative result on the comprehensive evaluation. 

After adjusting for patient characteristics, there can continue to be associations between the comprehensive TBI evaluation result and health care utilization and cost. There were 1.1 times more rehabilitation care visits, 1.2 times more polytrauma, and a little over 1.04 more mental health care visits and total health care costs after making adjustments were $972 higher for Veterans with a confirmed TBI though the comprehensive evaluation. 

Among the other characteristics and associated with health care utilization and cost, being male was associated with fewer primary care and other specialty care visits and lower health care costs. Being evacuated from the theater was associated with greater odds of hospitalization, more primary care, more rehabilitation care, more specialty care and higher total costs. 

Among the comorbidities, Veterans with diagnoses of psychosis and substance use disorder, had the greatest association with cost. Veterans with substance use disorder had higher odds of hospitalization as well as higher cost than patients without those conditions. 

So in summary then, regarding the overall health care utilization and cost, Veterans with positive results on the TBI screen, had over 70% higher annual health care costs than Veterans who screen negative. And over 180% higher costs than Veterans with no TBI screening. Veterans with the positive TBI screen are symptomatic by definition which likely contributes then to the greater healthcare utilization and higher costs. Among the Veterans who receive the comprehensive evaluation total cost were 14% higher for Veterans with a confirmed diagnoses of TBI than those without diagnoses of TBI. 

Additionally, we found that a substantial portion of services that were used were for mental health care during the 12 months following the index date. The largest number of outpatient visits were for mental health care clinics. Additionally, we found that over 40% of inpatient days in VA facilities, were for mental health care. Among the ideologies related to hospitalization, psychosis and substance use resulted in significantly higher odds of hospitalization. 

So, over all then, the study highlights the additional resources that are needed to provide care for Veterans with TBI relative to other Veterans. For example, we found that while over 20% of Veterans had a positive TBI screen, they accounted for over 30% of the total health care cost among the Veterans who received the screening. For those Veterans who received the screening, the total health care cost during this one year period were $997,000,000. Then in comparison to previous estimate of the average health care of all VA users, about $5,700 which was from a congressional budget office report, the average annual cost of health care for Veterans with a TBI confirmed through the comprehensive evaluation at over $12,000 was more than twice the average for4 all VA users. So again, these are just two examples indicating how this patient population, the patients with TBI, are requiring additional resource needs that the VA should be aware of relative to other Veterans receiving health care within the VA. 

So, given that the prevalence of TBI either with or without other conditions, in OEF/OIF Veterans, evidence about the resources required to provide care for the Veterans who are screened for TBI is going to be very important to VA health care planners. Common treatment needs for Veterans with TBI may include cognitive behavioral intervention, pain management, assistive devices and other specialty consultation. 

So the provision of adequate resources to address the mental healthcare needs will be particularly important because mental health then psycho social conditions are among the substantial portion of the Veterans then, both identified in previous studies and identified in the current study. Similar to previous reports, we also found that PTSD was highly prevalent among the OEF/OIF Veterans and that the proportion differed by the TBI screening groups which was what we found in this study. The proportion of patients with PTSD who screened positive on the TBI screen, was more than twice the portion of Veterans who screened negative. There were 32% who screened positive were on PTSD where as 14% who screened negative were found to have that in this particular study. So it is not surprising that a substantial portion of the health care following the index visit was for mental health related care, particularly for patients who screen positive on the TBI screening.    

We also found that Veterans with mental health conditions including PTSD had more hospitalization and more outpatient visits than Veterans without those conditions. So, overall then, the results from the screening they can, it might be the case that this can assist clinicians and policy makers in anticipating the scope and the type of services that are needed by OEF/OIF Veterans. 

We do not want to point out some limitations to the study as I noted previously. During a large period of the study period, the comprehensive TBI evaluation was not available system wide, or fully utilized across the VA system. And so that is our group of patients that we examined who had the comprehensive evaluation, was not the full set of individuals who screened positive on the TBI screen. Additionally, some Veterans may have had private insurance or received other non VA care that was not captured by the VA T basis files. As a result, our cost estimates may not fully capture the total cost of treating these patients. And additionally, the duration of our service use, was not examined beyond 12 months. So planning for lifetime care and the needs for more protracted duration would be an area in need of further study.

So in conclusion then, over the 12 months following the their initial evaluation, Veterans with positive results on the TBI screen had higher total costs than Veterans that screened negative, and more than double the cost with patients with no screening. And understanding the health care utilization and cost patterns following the TBI screening will be important to for policy makers to address the ongoing and future health care needs of the returning OEF/OIF Veterans. And we have also presented some references that were useful for this study, and now for any questions?

Bob Kerns:Sure, thank you Kevin, very interesting presentation. We do have some questions that have come in. One of the questions has to do with just understanding a little bit about the cohorts that you analyzed. You started off by saying people who were not screened, people who were screened positive and negative, and then you asked a separate population of CTVI positive and negative. Are they nested?

Kevin Stroupe:They – yes the TBI, the patients who had the comprehensive evaluation were a subset. In this analysis, the patients who had the comprehensive evaluation were a subset of the patients who screened positive on the TBI screen.

Bob Kerns:Can you answer the question about whether the CTVI screening is worth it, so this extra effort that you are going through in this screening, is it making a difference, or is it just adding a layer of administrative complexity?

Kevin Stroupe:Well that – with the data that we did see that the patients that had the TBI screen appeared to have a perhaps different trajectory than a future healthcare utilization and cost than patients who screen negative, or patients who were without the screening. So to the extent that might be useful for future planning purposes, that is one area. But as far as the additional administrative burden and the worthwhile of that, I mean that also leads to the issue that we were only looking at a relatively short-term scope of cause of how this might play out over having this information over a longer time period. That enough? 

Bob Kerns:Okay, because I think one of the questions that the person was asking was looking at the cost differentials and they are one slide, I think 21 is $27.00. And another slide it is $293.00, and this person was trying to grapple with why is there the difference, and is it just the difference in the cohorts that you are analyzing here, or is there something else going on that is driving those differences?

 Kevin Stroupe:Oh the slide like 20 or so.

Unidentified Male:Twenty-one is what they mention in their...oops that is 29, 27, keep going up, 26, 25, they were looking there, and they showed, they mentioned the $27 screen negative versus $293 as a difference. But then later on the difference is higher. So they were interested in that comprehensive TBI evaluation.

Kevin Stroupe:Well that – so the case with – I mean this – again we noted that across the groups there were sort of substantial differences in the health care characteristics among the various patients. So what we are finding, we can mostly describe as sort of associations between the screening results and the patients, we were not identifying strictly causation with this. But as far as the – there were across the differences, different cost patterns, differences in terms of the – more or less in terms of the magnitude of the cost that were being identified. But then we did see again overall for patients screened positive and then went on to have the comprehensive evaluation. Again, we only had information for a subset of those patients and so as that becomes more widely available, within the system, some additional followup to examine the impact among that group might also be of use.  

Bob Kerns:Alright thanks. Two more questions, one, we found many Veterans who screened multiple times – who were screened multiple times and even had multiple evaluations, often with different results. Do you take this into account in your analysis?

Kevin Stroupe:Regarding whether Veterans were screened multiple times?

Bob Kerns:Yeah, I guess it is also the issue that sometimes when they are screened multiple times, they might have a positive screen and a negative screen. So it is not always consistent.

Kevin Stroupe:Let me see, with that, I believe we took the most recent screen, but I would have to go back and confirm that regarding the analysis of the patients with the most – that might have had multiple screenings.

Bob Kerns:Okay, and then another question is, do you know of other researchers who are examining similar research questions related to cost associated with TBI in Veterans/military populations? If so, can you discuss any differences in the scope of the studies or highly related findings?

Kevin Stroupe:Well, this overall effort was in response to a specific solicitation regarding the screening and the comprehensive evaluation and so on that would be the case that others would be involved with. Yes, I could followup in terms of who else might be involved with this sort of work, but a lot of the other work was focused on more of the clinical aspects of the comprehensive first use of the screening. But as I said, this particular project was SDR that was from a – in response to a solicitation that there were sort of multiple awards for, so other people have been looking into the TBI screen, that is true.

Bob Kerns:Now I think it is Justice Glitz [PH] and Linda Belms [PH] have received considerable attention regarding their estimates, you know Linda is at Harvard and Justice is at Columbia, and they have made a number of projections of VA spending for OEF/OIF Veterans. And it has received considerable debate about sort of the cost of future wars. Have you had any chance to think about how this might project into the future?

Kevin Stroupe:We have not looked at that specifically, but that certainly would be another next step to go with this because what we were, as I noted, this was only a limitation, that we were only looking at a year. But the fact that these particular patients, most of the – the conditions that we are looking at are not necessarily life threatening so the patients do have a – will be potentially be incurring utilization for many more years to come. So taking, trying to go forward is the next step in looking at what some longer term costs with this would be. That would certainly be an important thing to look at. But we have not specifically addressed that at this point. 

Unidentified Male:Okay, and then you later in the talk you have a bunch of citations, do those citations include the other studies that you mentioned that were funded as part of this solicitation, and where could someone who is interested in this area go for more information. Is there an operational partner that you have?

Kevin Stroupe:Let us see, that – the citations, they were specifically related to this particular analysis, but we could certainly get back to you that could be distributed later, who some others involved in this might have been. I mean who are involved with the evaluation of the TBI screening.

Bob Kerns:So Kevin, for this person, it is okay if they contact you offline for example and just ask you privately?

Kevin Stroupe:Oh sure, yeah.

Bob Kerns:That would be great, yeah. That was the last question that we had and we are right at the top of the hour. So I wanted to thank you Kevin for a great presentation on TBI costs and utilization.

Kevin Stroupe:Oh, thank you.

Bob Kerns:Hopefully the feedback was helpful for you and hopefully everybody else enjoyed the talk. And thanks everybody for the different hour of the cyber seminar this month. So shifting by one hour, hopefully that was convenient for folks.

Moderator:Hope we had more people in Alaska and Hawaii able to join us this month. 

Bob Kerns:Is that often a problem?

Moderator: They are usually way too early for them. And Todd, I would love to publicize you next session in the series but I do not have one right now, so...

Bob Kerns:I think we had to postpone it because of the national meeting. We had guests, so I do not know if we have one scheduled for July. So hopefully we will see many of you at the national meeting and feel free to say hi if you are there.

Moderator:And for everyone else, we will be sending out registration materials for the next session as soon as we have a schedule.

Bob Kerns:Sounds great.

Moderator:Thank you everyone for joining us today, and we will see you at a future session, thank you. 

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