Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.

BACKGROUND: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). METHODS: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. RESULTS: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. CONCLUSIONS: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

Is fragmented financing bad for your health?

Americans finance health care through a variety of private insurance plans and public programs. This organizational fragmentation could threaten continuity of care and adversely affect outcomes. Using a large sample of veterans who were eligible for mixtures of Veterans Health Administration- and Medicare-financed care, we estimate a system of equations to account for simultaneity in the determination of financing configuration and the probability of hospitalization for an ambulatory care sensitive condition. We find that a change of one standard deviation in financing fragmentation increases the risk of an adverse outcome by one-fifth.

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.

Designing Media for Visually-Impaired Users of Refreshable Touch Displays: Possibilities and Pitfalls.

This paper discusses issues of importance to designers of media for visually impaired users. The paper considers the influence of human factors on the effectiveness of presentation as well as the strengths and weaknesses of tactile, vibrotactile, haptic, and multimodal methods of rendering maps, graphs, and models. The authors, all of whom are visually impaired researchers in this domain, present findings from their own work and work of many others who have contributed to the current understanding of how to prepare and render images for both hard-copy and technology-mediated presentation of Braille and tangible graphics.