Multisensory impairment reported by veterans with and without mild traumatic brain injury history

With the use of Veterans Health Administration and Department of Defense databases of veterans who completed a Department of Veterans Affairs comprehensive traumatic brain injury (TBI) evaluation, the objectives of this study were to (1) identify the co-occurrence of self-reported auditory, visual, and vestibular impairment, referred to as multisensory impairment (MSI), and (2) examine demographic, deployment-related, and mental health characteristics that were potentially predictive of MSI. Our sample included 13,746 veterans with either a history of deployment-related mild TBI (mTBI) (n = 9,998) or no history of TBI (n = 3,748). The percentage of MSI across the sample was 13.9%, but was 17.4% in a subsample with mTBI history that experienced both nonblast and blast injuries. The factors that were significantly predictive of reporting MSI were older age, being female, lower rank, and etiology of injury. Deployment-related mTBI history, posttraumatic stress disorder, and depression were also significantly predictive of reporting MSI, with mTBI history the most robust after adjusting for these conditions. A better comprehension of impairments incurred by deployed servicemembers is needed to fully understand the spectrum of blast and nonblast dysfunction and may allow for more targeted interventions to be developed to address these issues.

Psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF VA patients with deployment-related traumatic brain injury: a gender comparison

BACKGROUND

Traumatic brain injury (TBI) has substantial negative implications for the post-deployment adjustment of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF); however, most research on veterans has focused on males. This study investigated gender differences in psychiatric diagnoses and neurobehavioral symptom severity among OEF/OIF veterans with deployment-related TBI.

METHODS

This population-based study examined psychiatric diagnoses and self-reported neurobehavioral symptom severity from administrative records for 12,605 United States OEF/OIF veterans evaluated as having deployment-related TBI. Men (n = 11,951) and women (n = 654) who were evaluated to have deployment-related TBI during a standardized comprehensive TBI evaluation in Department of Veterans Affairs facilities were compared on the presence of psychiatric diagnoses and severity of neurobehavioral symptoms.

FINDINGS

Posttraumatic stress disorder (PTSD) was the most common psychiatric condition for both genders, although women were less likely than men to have a PTSD diagnosis. In contrast, relative to men, women were 2 times more likely to have a depression diagnosis, 1.3 times more likely to have a non-PTSD anxiety disorder, and 1.5 times more likely to have PTSD with comorbid depression. Multivariate analyses indicated that blast exposure during deployment may account for some of these differences. Additionally, women reported significantly more severe symptoms across a range of neurobehavioral domains.

CONCLUSION

Although PTSD was the most common condition for both men and women, it is also critical for providers to identify and treat other conditions, especially depression and neurobehavioral symptoms, among women veterans with deployment-related TBI.

Costs of home versus inpatient treatment for fever and neutropenia: analysis of a multicenter randomized trial

PURPOSE

For patients with cancer who have febrile neutropenia, relative costs of home versus hospital treatment, including unreimbursed costs borne by patients and families, are poorly characterized. We estimated costs from a randomized trial of patients with low-risk febrile neutropenia for whom outpatient care was feasible, comparing inpatient treatment with discharge to home care after inpatient observation.

METHODS

We collected direct medical and self-reported indirect costs for 57 inpatient and 35 outpatient treatment episodes of patients enrolled in a randomized trial from 1996 through 2000. Charges from hospital bills were converted to costs using Medicare cost-to-charge ratios. Patients kept daily logs of out-of-pocket payments and time spent by informal caregivers providing care. Dollar amounts were standardized to June 2008.

RESULTS

Mean total charges for the hospital arm were 49% higher than for the home treatment arm ($16,341 v $10,977; P < .01). Mean estimated total costs for the hospital arm were 30% higher ($10,143 v $7,830; P < .01). Inspection of sparse available data suggests that payments made were similar by treatment arm. Inpatients and their caregivers spent more out of pocket than their outpatient counterparts (mean, $201 v $74; P < .01). Informal caregivers for both treatment arms reported similar time caring and lost from work.

CONCLUSION

Home intravenous antibiotic treatment was less costly than continued inpatient care for carefully selected patients with cancer having febrile neutropenia without significantly increased indirect costs or caregiver burden.

Controlling prescription drug costs: regulation and the role of interest groups in Medicare and the Veterans Health Administration

Medicare and the Veterans Health Administration (VA) both finance large outpatient prescription drug programs, though in very different ways. In the ongoing debate on how to control Medicare spending, some suggest that Medicare should negotiate directly with drug manufacturers, as the VA does. In this article we relate the role of interest groups to policy differences between Medicare and the VA and, in doing so, explain why such a large change to the Medicare drug program is unlikely. We argue that key policy differences are attributable to stable differences in interest group involvement. While this stability makes major changes in Medicare unlikely, it suggests the possibility of leveraging VA drug purchasing to achieve savings in Medicare. This could be done through a VA-administered drug-only benefit for Medicare-enrolled veterans. Such a partnership could incorporate key elements of both programs: capacity to accept large numbers of enrollees (like Medicare) and leverage to negotiate prescription drug prices (like the VA). Moreover, it could be implemented at no cost to the VA while achieving savings for Medicare and beneficiaries.

Health care resource utilization and expenditures associated with the use of insulin glargine

BACKGROUND

Newer insulins, such as long-acting analogues, offer promise of better glycemic control, reduced risk for diabetes complications, and moderation of health care use and costs.

OBJECTIVE

We studied initiation of insulin glargine to evaluate its association with subsequent health service utilization and estimated expenditures.

METHODS

Patients of the Veterans Health Administration, US Department of Veterans Affairs (VA) who initiated insulin glargine (n=5064) in 2001-2002 were compared with patients receiving other insulin (n=69,944), matched on prescription month (index date). Inpatient and outpatient VA care in the 12 months after a patient's index date was evaluated using Tobit regression, controlling for prior utilization, demographic characteristics, comorbidities, glycosylated hemoglobin (HbA(1c)) levels, and diabetes severity. National average utilization costs and medication acquisition costs were used to estimate the value of VA expenditures.

RESULTS

Compared with other insulin users, insulin glargine initiators had higher HbA(1c) values (8.72% vs 8.16%) prior to the index date, but greater subsequent HbA(1c) reduction (-0.50% vs -0.22%). After adjustment for age, prior utilization, HbA(1c) levels, and other factors, insulin glargine initiation was associated with 2.4 (95% CI, 1.1-3.7) fewer inpatient days for patients with any hospital admission (US $820 lower costs per initiator), 1.6 (1.2-1.9) more outpatient encounters ($279 higher costs per initiator), and $374 ($362-$387) higher costs for diabetes medications. The net difference was an average lower VA cost of $166 (-$290 to $622) per patient.

CONCLUSIONS

Insulin glargine use was associated with decreased inpatient days but increased outpatient care, and the value of the net change in utilization to VA offset the additional medication expenditures. Initiation of insulin glargine improves glycemic control and may reduce time in hospital without additional use of health resources.

Patient recruitment to a randomized clinical trial of behavioral therapy for chronic heart failure

Background

Patient recruitment is one of the most difficult aspects of clinical trials, especially for research involving elderly subjects. In this paper, we describe our experience with patient recruitment for the behavioral intervention randomized trial, "The relaxation response intervention for chronic heart failure (RRCHF)." Particularly, we identify factors that, according to patient reports, motivated study participation.

Methods

The RRCHF was a three-armed, randomized controlled trial designed to evaluate the efficacy and cost of a 15-week relaxation response intervention on veterans with chronic heart failure. Patients from the Veterans Affairs (VA) Boston Healthcare System in the United States were recruited in the clinic and by telephone. Patients' reasons for rejecting the study participation were recorded during the screening. A qualitative sub-study in the trial consisted of telephone interviews of participating patients about their experiences in the study. The qualitative study included the first 57 patients who completed the intervention and/or the first follow-up outcome measures. Factors that distinguished patients who consented from those who refused study participation were identified using a t-test or a chi-square test. The reason for study participation was abstracted from the qualitative interview.

Results

We successfully consented 134 patients, slightly more than our target number, in 27 months. Ninety-five of the consented patients enrolled in the study. The enrollment rate among the patients approached was 18% through clinic and 6% through telephone recruitment. The most commonly cited reason for declining study participation given by patients recruited in the clinic was 'Lives Too Far Away'; for patients recruited by telephone it was 'Not Interested in the Study'. One factor that significantly distinguished patients who consented from patients who declined was the distance between their residence and the study site (t-test: p < .001). The most frequently reported reason for study participation was some benefit to the patient him/herself. Other reasons included helping others, being grateful to the VA, positive comments by trusted professionals, certain characteristics of the recruiter, and monetary compensation.

Conclusions

The enrollment rate was low primarily because of travel considerations, but we were able to identify and highlight valuable information for planning recruitment for future similar studies.

Evaluating VA patient-level expenditures: decision support system estimates and Medicare rates

OBJECTIVES

To make preliminary comparisons of Veterans Health Administration (VA) Decision Support System (DSS) patient-level cost information with Medicare allowable reimbursements.

METHODS

For six VA facilities in the Evaluating VA Costs study for federal fiscal year 1999, DSS cost estimates for outpatient inguinal hernia and cataract operations and inpatient stays for chronic obstructive pulmonary disease, simple pneumonia, diabetes, and detoxification were compared with Medicare allowable reimbursement amounts for the same procedures and diagnosis-related groups. Medicare average base payments were adjusted for disproportionate share, capital, and indirect medical education costs. The amounts include Medicare's geographic adjustments for wages and capital. Medicare professional fees were a weighted average of site-specific fees paid for the indicated procedure.

RESULTS

For the chosen types of care in fiscal year 1999, average DSS cost estimates were generally higher than estimated Medicare allowable reimbursement amounts, but included different amounts of professional services per discharge or outpatient procedure. The difference was greatest for inguinal hernia repair ($3253 US dollars compared with $1506 US dollars). Two diagnosis-related groups for detoxification (434 and 435) were least comparable between the systems because some VA discharges undoubtedly included both acute and nonacute portions of the hospitalizations, whereas the Medicare rates are for acute stays only.

CONCLUSIONS

Researchers and managers need DSS detail records to make any meaningful comparisons of the VA's DSS costs and non-VA reimbursement amounts such as those of Medicare. Non-VA reimbursement estimates should include an average of all professional services, including those of anesthesiologists and consultants. Separating acute and nonacute bedsections in DSS data would improve the VA's capability for comparison. Current information is insufficient for make or buy decisions.

Private sector coverage of people with dual diagnoses

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Cost analysis in the Department of Veterans Affairs: consensus and future directions

OBJECTIVES

In 1997, the Management Decision and Research Center of the Department of Veterans Affairs convened cost experts and health economists in a working meeting. Its goal was to provide consensus guidelines for conducting cost analyses in managed care systems, such as VA, that do not have encounter-level cost data or that do not prepare itemized patient bills. The impetus for the meeting was that too often computer-based cost data were proposed or used in studies that were inappropriate for the question being addressed. There was also a sense that often great effort was being expended by VA health economists "reinventing the wheel" in developing new cost components for each study.

METHODS

A group of 45 VA and non-VA health economists, health researchers, and policy-makers attended a 2 day working meeting organized around a series of case vignettes to identify areas of consensus, controversy, and gaps in knowledge.

RESULTS

Consensus emerged in the following four areas: (1) Cost Methods. A "hybrid model" was identified as the current standard of cost analysis in VA and entails mixing "micro-costing" primary data collection and "gross-cost" computer-based methods to reflect resource-use variations that are essential to the research question. (2) Cost Infrastructure. VA is developing a new, but unevaluated, costing system that could allow for computer-based cost analyses at much finer levels of detail than is currently possible. (3) Data Quality. Ongoing data validation of existing and developing cost databases is needed, especially concerning interfacility variation. (4) Dissemination. A new cost data center was recommended to provide training, information dissemination, and coordination.

CONCLUSIONS

Consensus was reached about the hybrid model as the current paradigm for cost analysis in systems like VA.

More or less?: Methods to compare VA and non-VA health care costs

OBJECTIVE

To examine past comparisons of the costs of the Veterans Health Administration (VA) and of non-VA providers to determine lessons and data requirements for future cost comparisons, particularly those assessing VA efficiency and to determine whether VA should purchase care from non-VA providers.

CONCEPTUAL FRAMEWORK

Over the past two decades, researchers have tried to establish how VA costs compare to those of non-VA health care delivery systems. Existing studies of overall acute care costs address one of two distinct questions: How do VA costs compare to costs in private sector hospitals? and Would it cost more to have VA patients treated in nonfederal hospitals? For both questions, the major factors underlying differences in health care costs are variations in outputs, input prices, and levels of efficiency. Health care cost comparisons across systems must also wrestle with accounting differences.

CONCLUSIONS

That review finds no convincing evidence that VA has been significantly more or less efficient than nonfederal hospitals in delivering care. However, VA costs do appear to have been significantly lower than fee-for-service charges that the federal government might have to pay if veterans were treated in private sector hospitals for the same diagnoses. Future comparisons of costs in the era of managed care will require better diagnostic and population data to control for observable and unobservable case-mix differences. They should also include measures of the quality of outcomes. Finally, consistent accounting practices, particularly in the treatment of capital costs, are needed.

Do individuals with substance abuse diagnoses incur higher charges than individuals with other chronic conditions?

Concerns about high costs have led to limits on the services covered by most insurance plans for substance abuse treatment. But, the commonly used comparison group for cost analyses, all enrollees in a health-care plan, may not be appropriate because addiction is a chronic condition. Therefore, to determine whether substance abusers incur higher charges than patients with other serious chronic conditions, we used health insurance information for employees and dependents over 3 years (1989 to 1991) for two firms with a total of almost 40,000 employees to do alternate comparisons. We compared average annual charges for patients with the following diagnoses: substance abuse, substance abuse with mental illness, arthritis, asthma, and diabetes. Patients who undergo treatment for abusing alcohol, drugs, or both often (but not always) incur higher charges than people with other chronic conditions. Clear differences in average charges emerge between patients with and without mental health claims.

Using health insurance claims data to analyze substance abuse charges and utilization

It is crucial to evaluate whether health insurance data sets will provide robust answers to significant research questions in advance of undertaking large research studies using these data. In this article, we present the research challenges of using insurance claims data sets to study substance abuse. Using illustrations from the itemized claims from three large employers, we focus on using administrative data to analyze costs to employers, utilization of services to treat abuse of specific drugs, and the effects of managed care strategies. We conclude that insurance claims data sets are useful for reporting employers' payments for treatment of identified substance abusers and for tracking changes over time but are not useful for studies of the use of treatment for specific drugs.

Characteristics of private-sector managed care for mental health and substance abuse treatment

OBJECTIVE

This study examined diversity during the late 1980s in managed care programs for mental health, alcohol abuse, and drug abuse to identify ways in which research can generate more meaningful data on the effectiveness of utilization review programs.

METHODS

Telephone interviews were conducted with representatives of utilization review programs for employee health insurance plans in 31 firms that employed 2.1 million people in 1990. Questions addressed qualifications of personnel, clinical criteria to authorize care, integration with employee assistance plans, penalties for not complying with utilization review procedures, outpatient review, and carve out of mental health and substance abuse review.

RESULTS

Large variations in utilization review programs were found. Programs employed a range of review personnel and used a variety of clinical criteria to authorize care. More than two-thirds did not carve out mental health and substance abuse review from medical-surgical review. Some firms' employee assistance plans were integrated with utilization review programs, while others remained unintegrated. Penalties for not following program procedures varied widely, as did review of outpatient services.

CONCLUSIONS

Because of trends toward even more diversity in utilization review programs in the 1990s, research that identifies the specific features of managed care programs that hold most promise for controlling costs while maintaining quality of care will increasingly be needed.

Measuring quality of care: fundamental information from administrative datasets

Under proposals for national health insurance reform in the USA, employers and purchasing cooperatives will have to measure the quality of health care services. Their need for data systems upon which to base their decisions has stimulated dramatic innovation and rapid change in how health care information is collected, integrated from multiple sources, and reported. To make administrative data useful for quality measurement, careful attention must be given to information about: medical care utilization; patient characteristics; provider characteristics; and health plans. In this paper, we describe the extent to which this information is included in existing administrative datasets. We then suggest how planned datasets should be designed so they can be used to assess the quality of health care.

How well do Americans understand their health coverage?

Data from two surveys are used in this DataWatch to explore Americans' understanding of their health insurance. First, data from a national survey of consumers are used to examine if people with private health insurance correctly report their coverage for six services. Second, information from an evaluation of a pilot project of subsidized insurance in New York is used to investigate how well newly insured persons understand their coverage. Based on these surveys, almost all privately insured people understand the basic elements of their insurance plans but underestimate their coverage for mental health, substance abuse, and prescription drug benefits and overestimate their coverage for long-term care. People who are newly insured in physician networks or health maintenance organizations seem uncertain about what services their plan covers and restrictions on their choice of hospitals.

Can practice guidelines reduce the number and costs of malpractice claims?

Practice guidelines have the potential to reduce the number of malpractice cases and the costs of settling them. However, for practice guidelines to exert any influence, they must be assumed to be (1) developed for conditions or procedures that frequently lead to events for which negligence claims are filed; (2) widely accepted in the medical profession; (3) fully integrated into clinical practice; and (4) straightforward and readily interpreted in a litigation setting. Because the validity of each of these assumptions can be questioned, the idea that inserting practice guidelines into the existing litigation process will generate large savings in the near future is overly optimistic.

Hospital wage gradients within U.S. urban areas

Average wages from 2,275 general hospitals in metropolitan areas across the U.S. were used to test for a wage gradient descending from hospitals in the central city through those in urbanized and finally non-urbanized areas of each county-defined metropolitan area. Significant gradients were found in MSAs of all sizes. Urbanized-area wages were 3 to 6 percent lower than those in central cities of the same metropolitan area. Non-urbanized suburban wages were 10 to 12 percent lower than those in central cities. The explanations for the gradients differ somewhat between large and small areas. For example, while the relative mix of high-wage and low-wage occupations in each hospital is a significant explanatory variable for wages in all metropolitan area sizes, the relative use of part-time workers is not significant in those metropolitan areas with fewer than 250,000 people. Relative crime in each hospital's city is highly significant in explaining relative wages only for areas with populations of more than one million.

Rural hospital wages

Average fiscal year 1982 wages from 2,302 rural American hospitals were used to test for a gradient descending from hospitals in counties adjacent to metropolitan areas to those not adjacent. Considerable variation in the ratios of adjacent to nonadjacent averages existed. No statistically significant difference was found, however. Of greater importance in explaining relative wages within States were occupational mix, mix of part-time and full-time workers, case mix, presence of medical residencies, and location in a high-rent county within the State. Medicare already adjusts payments for only two of these variables.