Relationships of Self-reported Opioid Use and Misuse and Pain Severity With Probable Major Depression Among Participants With Spinal Cord Injury.

OBJECTIVES: To examine the relations of pain intensity, opioid use, and opioid misuse with depressive symptom severity and probable major depression (PMD) among participants with spinal cord injuries (SCI), controlling for demographic, injury, and socioeconomic characteristics. STUDY DESIGN: Cohort study. SETTING: Medical University in the Southeastern United States (US). PARTICIPANTS: Participants (N=918) were identified from 1 of 2 sources including a specialty hospital and a state-based surveillance system in the Southeastern US. Participants were a minimum of 18 years old at enrollment and had SCI with non-complete recovery. Participants were on average 57.5 years old at the time of the study and an average of 24.4 years post SCI onset. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed a self-report assessment that included frequency of prescription opioid use and misuse, based on the National Survey on Drug Use and Health (NSDUH), and the PHQ - 9 to measure depressive symptom severity and PMD. RESULTS: Opioid use, opioid misuse, and pain intensity were related to elevated depressive symptom severity and higher odds of PMD. Non-Hispanic Blacks had fewer depressive symptoms and lower odds of PMD, as did those with higher incomes. Veterans had lower risk of PMD, whereas ambulatory participants had a higher risk of PMD. Age at SCI onset had a mixed pattern of significance, whereas years of education and years since injury were not significant. CONCLUSIONS: The relation between pain intensity with depressive symptom severity and PMD was profound, consistent with the biopsychosocial model of pain. The greater risk of PMD and higher depressive symptom severity among those using opioids and misusing opioids raises further concern about long-term prescription opioid use. Alternative treatments are needed.

Self-Reported Prescription Opioid Use Among Participants with Chronic Spinal Cord Injury.

Background: Individuals with spinal cord injuries (SCI) experience high rates of prescription opioid use, yet there is limited data on frequency of opioid use and specific medications being taken. Objectives: To examine the frequency of self-reported prescription opioid use among participants with SCI and the relationship with demographic, injury, and socioeconomic characteristics. Methods: A cohort study of 918 adults with SCI of at least 1-year duration completed a self-report assessment (SRA) that indicated frequency of specific prescription opioid use based on the National Survey on Drug Use and Health (NSDUH). Results: Forty-seven percent of the participants used at least one prescription opioid over the last year; the most frequently used was hydrocodone (22.1%). Nearly 30% used a minimum of one opioid at least weekly. Lower odds of use of at least one opioid over the past year was observed for Veterans (odds ratio [OR] = 0.60, 95% CI = 0.38, 0.96) and those with a bachelor's degree or higher (OR = 0.63, 95% CI = 0.44, 0.91). When restricting the analysis to use of at least one substance daily or weekly, lower odds of use was observed for those with a bachelor's degree or higher and those with income ranging from $25,000 to $75,000+. None of the demographic or SCI variables were significantly related to prescription opioid use. Conclusion: Despite the widely established risks, prescription opioids were used daily or weekly by more than 28% of the participants. Usage was only related to Veteran status and socioeconomic status indicators, which were protective of use. Alternative treatments are needed for those with the heaviest, most regular usage.

The Clinical Resource Hub Telehealth Program and Use of Primary Care, Emergency, and Inpatient Care During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic disrupted delivery of health care services worldwide. We examined the impact of the pandemic on clinics participating in the Veterans Affairs (VA) Clinical Resource Hub (CRH) program, rolled out nationally in October 2019, to improve access to care at under-resourced VA clinics or "spoke" sites through telehealth services delivered by regional "hub" sites. OBJECTIVE: To assess whether the CRH program was associated with increased access to primary care, we compared use of primary, emergency, and inpatient care at sites that adopted CRH for primary care (CRH-PC) with sites that did not adopt CRH-PC, pre-post pandemic onset. DESIGN: Difference-in-difference and event study analyses, adjusting for site characteristics. STUDY COHORT: A total of 1050 sites (254 CRH-PC sites; 796 comparison sites), fiscal years (FY) 2019-2021. INTERVENTION: CRH Program for Primary Care. MAIN MEASURES: Quarterly number of VA visits per site for primary care (across all and by modality, in-person, video, and phone), emergency care, and inpatient care. RESULTS: In adjusted analyses, CRH-PC sites, compared with non-CRH-PC sites, had on average 221 additional primary care visits (a volume increase of 3.4% compared to pre-pandemic). By modality, CRH-PC sites had 643 fewer in-person visits post-pandemic (- 14.4%) but 723 and 128 more phone and video visits (+ 39.9% and + 159.5%), respectively. CRH-PC sites, compared with non-CRH-PC sites, had fewer VA ED visits (- 4.2%) and hospital stays (- 5.1%) in VA medical centers. Examining visits per patient, we found that CRH-PC sites had 48 additional telephone primary care visits per 1000 primary care patients (an increase of 9.8%), compared to non-program sites. CONCLUSIONS: VA's pre-pandemic rollout of a new primary care telehealth program intended to improve access facilitated primary care visits during the pandemic, a period fraught with care disruptions, and limited in-person health care delivery, indicating the potential for the program to offer health system resilience.

Risk of Adverse Outcomes Among Veterans Who Screen Positive for Traumatic Brain Injury in the Veterans Health Administration But Do Not Complete a Comprehensive Evaluation: A LIMBIC-CENC Study.

OBJECTIVE: To examine whether post-9/11 veterans who screened positive for mild traumatic brain injury (mTBI) but did not complete a Comprehensive TBI Evaluation (CTBIE) were at higher risk of subsequent adverse events compared with veterans who screened positive and completed a CTBIE. Upon CTBIE completion, information assessed by a trained TBI clinician indicates whether there is mTBI history (mTBI+) or not (mTBI-). SETTING: Veterans Health Administration (VHA) outpatient services. PARTICIPANTS: A total of 52 700 post-9/11 veterans who screened positive for TBI were included. The follow-up review period was between fiscal years 2008 and 2019. The 3 groups studied based on CTBIE completion and mTBI status were: (1) mTBI+ (48.6%), (2) mTBI- (17.8%), and (3) no CTBIE (33.7%). DESIGN: This was a retrospective cohort study. Log binomial and Poisson regression models adjusting for demographic, military, pre-TBI screening health, and VHA covariates examined risk ratios of incident outcomes based on CTBIE completion and mTBI status. MAIN MEASURES: Incident substance use disorders (SUDs), alcohol use disorder (AUD), opioid use disorder (OUD), overdose, and homelessness documented in VHA administrative records, and mortality as documented in the National Death Index, 3 years post-TBI screen. VHA outpatient utilization was also examined. RESULTS: Compared with the no CTBIE group, the mTBI+ group had 1.28 to 1.31 times the risk of incident SUD, AUD, and overdose, but 0.73 times the risk of death 3 years following TBI screening. The mTBI- group had 0.70 times the risk of OUD compared with the no CTBIE group within the same period. The no CTBIE group also had the lowest VHA utilization. CONCLUSIONS: There were mixed findings on risk of adverse events for the no CTBIE group relative to the mTBI+ and mTBI- groups. Future research is needed to explore the observed differences, including health conditions and healthcare utilization, documented outside VHA among veterans who screen positive for TBI.

Effect of Post-traumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA). DESIGN: Multivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data. SETTING: Five VA PRCs. PARTICIPANTS: VA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717). INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Total, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals. RESULTS: A total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse. CONCLUSIONS: This study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.

Changes in Outpatient Healthcare Utilization and Costs Following Mild Traumatic Brain Injury Among Service Members in the Military Health System by Preexisting Behavioral Health Condition Status.

OBJECTIVE: To evaluate changes in healthcare utilization and cost following an index mild traumatic brain injury (mTBI) diagnosis among service members (SMs). We hypothesized that differences in utilization and cost will be observed by preexisting behavioral health (BH) diagnosis status. SETTING: Direct care outpatient healthcare facilities within the Military Health System. PARTICIPANTS: A total of 21 984 active-duty SMs diagnosed with an index mTBI diagnosis between 2017 and 2018. DESIGN: This retrospective study analyzed changes in healthcare utilization and cost in military treatment facilities among SMs with an index mTBI diagnosis. Encounter records 1 year before and after mTBI were assessed; preexisting BH conditions were identified in the year before mTBI. MAIN MEASURES: Ordinary least squares regressions evaluated difference in the average change of total outpatient encounters and costs among SMs with and with no preexisting BH conditions (eg, posttraumatic stress disorder, adjustment disorder). Additional regressions explored changes in utilization and cost within clinic types (eg, mental health, physical rehabilitation). RESULTS: There was a 39.5% increase in overall healthcare utilization during the following year, representing a 34.8% increase in total expenditures. Those with preexisting BH conditions exhibited smaller changes in overall utilization (ß, -4.9; [95% confidence interval (CI), -6.1 to -3.8]) and cost (ß, $-1873; [95% CI, $-2722 to $-1024]), compared with those with no BH condition. The greatest differences were observed in primary care clinics, in which those with prior BH conditions exhibited an average decreased change of 3.2 encounters (95% CI, -3.5 to -3) and reduced cost of $544 (95% CI, $-599 to $-490) compared with those with no prior BH conditions. CONCLUSION: Despite being higher utilizers of healthcare services both pre- and post-mTBI diagnosis, those with preexisting BH conditions exhibited smaller changes in overall cost and utilization. This highlights the importance of considering prior utilization and cost when evaluating the impact of mTBI and other injury events on the Military Health System.

Alternative Structure Models of the Traumatic Brain Injury Rehabilitation Needs Survey: A Veterans Affairs TBI Model Systems Study.

OBJECTIVE: To explore the factor structure of the Rehabilitation Needs Survey (RNS). DESIGN: Secondary analysis of observational cohort study who were 5-years post-traumatic brain injury (TBI). SETTING: Five Inpatient Rehabilitation Facilities. PARTICIPANTS: Veterans enrolled in the TBI Model Systems longitudinal study who completed the RNS at 5-year follow-up (N=378). MAIN OUTCOME MEASURE(S): RNS. RESULTS: RNS factor structure was examined with exploratory factor analysis (EFA) with oblique rotation. Analyses returned 2- and 3-factor solutions with Cronbach alphas ranging from 0.715 to 0.905 and corrected item-total correlations that ranged from 0.279 to 0.732. The 2-factor solution accounted for 61.7% of the variance with ≥3 exclusively loading items on each factor with acceptable internal consistency metrics and was selected as the most parsimonious and clinically applicable model. Ad hoc analysis found the RNS structure per the EFA corresponded with elements of the International Classification of Functioning, Disability and Health (ICF) conceptual framework. All factors had adequate internal consistency (α≥0.70) and 20 of the 21 demonstrated good discrimination (corrected item-total correlations≥0.40). CONCLUSIONS: The 2-factor solution of the RNS appears to be a useful model for enhancing its clinical interpretability. Although there were cross-loading items, they refer to complex rehabilitation needs that are likely influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination.

Rural and urban differences in the implementation of Virtual Integrated Patient-Aligned Care Teams.

PURPOSE: Workforce shortages contribute to geographic disparities in accessing primary care services. An innovative, clinic-to-clinic videoconferencing telehealth program in the Veterans Health Administration (VHA) called the Virtual Integrated Patient-Aligned Care Teams (V-IMPACT) was designed to increase veterans' access to primary care and relieve workforce shortages in VA primary care clinics, including in many rural areas. This paper describes trends in clinic sites and veteran uptake of the V-IMPACT program, a model that delivered remote, team-based primary care services, from fiscal years (FY)2013-2018. METHODS: This observational study used VHA administrative data to compare program uptake, measured by the program penetration rate (percent of patients using V-IMPACT services in each site) across sites; and characteristics for V-IMPACT users versus nonusers for 2,155,203 veteran-years in 69 sites across 7 regional networks for FY2013-2018. Regression models assessed the association between V-IMPACT use and veteran characteristics within sites. FINDINGS: Across sites, V-IMPACT had higher penetration in rural sites (8%) and primary care community-based outpatient clinics (7%, P<.001). After adjusting for veteran characteristics, rural veterans (aOR = 1.05; P = .02) and veterans with higher comorbidity risk scores (aOR = 1.08; P<.001) were independently associated with V-IMPACT use. Highly rural veterans (OR = 0.60; P<.001) and veterans who lived ≥40 miles from the closest VHA primary care site (OR = 0.86; P<.001) were less likely to be a V-IMPACT user. CONCLUSIONS: A clinic-to-clinic telehealth program, such as V-IMPACT, was able to reach many rural sites, rural veterans, and veterans in primary care health professional shortage areas. V-IMPACT has the potential to increase access to team-based primary care.

Mild traumatic brain injury, PTSD symptom severity, and behavioral dyscontrol: a LIMBIC-CENC study.

Background: Behavioral dyscontrol occurs commonly in the general population and in United States service members and Veterans (SM/V). This condition merits special attention in SM/V, particularly in the aftermath of deployments. Military deployments frequently give rise to posttraumatic stress disorder (PTSD) and deployment-related mild TBI traumatic brain injury (TBI), potentially leading to manifestations of behavioral dyscontrol. Objective: Examine associations among PTSD symptom severity, deployment-related mild traumatic brain injury, and behavioral dyscontrol among SM/V. Design: Secondary cross-sectional data analysis from the Long-Term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium prospective longitudinal study among SM/V (N = 1,808). Methods: Univariable and multivariable linear regression models assessed the association and interaction effects between PTSD symptom severity, as assessed by the PTSD Checklist for the Diagnostic and Statistical Manual, 5th edition (PCL-5), and deployment-related mild TBI on behavioral dyscontrol, adjusting for demographics, pain, social support, resilience, and general self-efficacy. Results: Among the 1,808 individuals in our sample, PTSD symptom severity (B = 0.23, 95% CI: 0.22, 0.25, p < 0.001) and deployment-related mild TBI (B = 3.27, 95% CI: 2.63, 3.90, p < 0.001) were significantly associated with behavioral dyscontrol in univariable analysis. Interaction effects were significant between PTSD symptom severity and deployment mild TBI (B = -0.03, 95% CI: -0.06, -0.01, p = 0.029) in multivariable analysis, indicating that the effect of mild TBI on behavioral dyscontrol is no longer significant among those with a PCL-5 score > 22.96. Conclusion: Results indicated an association between PTSD symptom severity, deployment-related mild TBI, and behavioral dyscontrol among SM/V. Notably, the effect of deployment-related mild TBI was pronounced for individuals with lower PTSD symptom severity. Higher social support scores were associated with lower dyscontrol, emphasizing the potential for social support to be a protective factor. General self-efficacy was also associated with reduced behavioral dyscontrol.

Characteristics Associated With Perceived Underemployment Among Participants With Spinal Cord Injury.

Objective: To identify job characteristics related to perceived underemployment among people with spinal cord injury (SCI), while controlling for demographic, injury, and educational factors. Design: Cross-sectional, logistic regression with predicted probabilities of underemployment. Setting: Medical University in the Southeastern United States. Participants: 952 were adults with traumatic SCI, all of whom were a minimum of 1-year post-injury and employed at the time of the study. They averaged 46.7 years of age, the majority were male (70.5%), and over half (52%) were ambulatory (N=952). Interventions: Not applicable. Main Outcome Measures: Perceived underemployment was defined and measured by a dichotomous variable (yes/no). Results: Demographic, injury, and educational factors explained only 4.8% of the variance in underemployment, whereas the full model explained 21.8%. Underemployment was significantly lower for women (odds ratio [OR]=0.66, 95% confidence interval [CI; .44, .98]), those who were either married or in a nonmarried couple (OR=0.63, 95% CI [.42, .93]), those with health benefits (OR=0.58, 95% CI [.37, .91]) and higher for those with lower earnings and occupations in the category of sales, professional/managerial. Postsecondary educational milestones, having received a promotion or recognition, and working full time were not identified as significant predictors in the multivariate model, although each was significantly related to a lower likelihood of underemployment when using a restricted model that controls only for demographics, SCI, and educational status (rather than all variables simultaneously). Age, years since injury, and injury severity were not significant. Conclusion: Underemployment is a concern among people with SCI and is more prevalent in low-paying jobs, without benefits, and opportunities for recognition and promotion. Vocational counseling strategies need to promote quality employment, including jobs with recognition and benefits.

Association Between Traumatic Brain Injury and Subsequent Cardiovascular Disease Among Post-9/11-Era Veterans.

Importance: Traumatic brain injury (TBI) was common among US service members deployed to Iraq and Afghanistan. Although there is some evidence to suggest that TBI increases the risk of cardiovascular disease (CVD), prior reports were predominantly limited to cerebrovascular outcomes. The potential association of TBI with CVD has not been comprehensively examined in post-9/11-era veterans. Objective: To determine the association between TBI and subsequent CVD in post-9/11-era veterans. Design, Setting, and Participants: This was a retrospective cohort study conducted from October 1, 1999, to September 30, 2016. Participants were followed up until December 31, 2018. Included in the study were administrative data from the US Department of Veterans Affairs and the Department of Defense from the Long-term Impact of Military-Relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium. Participants were excluded if dates did not overlap with the study period. Data analysis was conducted between November 22, 2021, and June 28, 2022. Exposures: History of TBI as measured by diagnosis in health care records. Main Outcomes and Measures: Composite end point of CVD: coronary artery disease, stroke, peripheral artery disease, and cardiovascular death. Results: Of the 2 530 875 veterans from the consortium, after exclusions, a total of 1 559 928 veterans were included in the analysis. A total of 301 169 veterans (19.3%; median [IQR] age, 27 [23-34] years; 265 217 male participants [88.1]) with a TBI history and 1 258 759 veterans (80.7%; median [IQR] age, 29 [24-39] years; 1 012 159 male participants [80.4%]) without a TBI history were included for analysis. Participants were predominately young (1 058 054 [67.8%] <35 years at index date) and male (1 277 376 [81.9%]). Compared with participants without a history of TBI, diagnoses of mild TBI (hazard ratio [HR], 1.62; 95% CI, 1.58-1.66; P < .001), moderate to severe TBI (HR, 2.63; 95% CI, 2.51-2.76; P < .001), and penetrating TBI (HR, 4.60; 95% CI, 4.26-4.96; P < .001) were associated with CVD in adjusted models. In analyses of secondary outcomes, all severities of TBI were associated with the individual components of the composite outcome except penetrating TBI and CVD death. Conclusions and Relevance: Results of this cohort study suggest that US veterans with a TBI history were more likely to develop CVD compared with veterans without a TBI history. Given the relatively young age of the cohort, these results suggest that there may be an increased burden of CVD as these veterans age and develop other CVD risk factors. Future studies are needed to determine if the increased risk associated with TBI is modifiable.

Economic impact of comorbid TBI-dementia on VA facility and non-VA facility costs, 2000-2020.

OBJECTIVE: There is evidence Traumatic Brain Injury (TBI) is associated with increased risk of dementia (D). We compared VA and non-VA facility costs associated with TBI+D and each diagnosis alone, relative to neither diagnosis, annually and over time, 2000-2020. METHODS: We estimated adjusted panel models of annual VHA costs in VA and non-VA facilities, stratified by age, and by TBI-dementia status. We also estimated cost for the TBI+D cohort by time since TBI and dementia diagnoses. All costs were 2021 inflation adjusted. RESULTS: Veterans <65 ($30,736) and ≥65 ($15,650) with TBI+D, while veterans <65 ($3,379) and ≥65 ($4,252) with TBI-only had higher annual total VHA costs, relative to neither diagnosis. Veterans with TBI+D < 65 ($42,864) and ≥65 ($72,424) had higher costs in years≥15 after TBI diagnosis, while <65 ($36,431) and ≥65 ($37,589) had higher costs in years ≥10 after dementia diagnosis. CONCLUSIONS: The main cost driver was inpatient non-VA facility costs. Veterans had continuously increasing inpatient care costs in non-VA facilities over time since their TBI and dementia diagnoses. Given budget constraints on the VA system, quality of care in non-VA facilities warrants comparison with VA facilities to make informed decisions regarding referrals to non-VA facilities.

A Primary Care Telehealth Pilot Program to Improve Access: Associations with Patients' Health Care Utilization and Costs.

Background: The Veterans Health Administration (VHA) piloted an innovative video telehealth program called Virtual Integrated Multisite Patient Aligned Care Teams (V-IMPACT) in fiscal year (FY) 2014. V-IMPACT set up one regional "hub" site where primary care (PC) teams provided regular PC through telehealth services to patients in outlying "spoke" sites that experienced gaps in provider coverage. We evaluated associations between clinic-level adoption of V-IMPACT and patients' utilization and VHA's costs for primary, emergency, and inpatient care. Materials and Methods: This observational study used repeated cross-sections of 208,612 unique veteran patients assigned to a PC team in 22 V-IMPACT spoke sites from FY2013 to FY2018. V-IMPACT adoption in a spoke site was indicated if more than 1% of patients assigned to PC in a site used V-IMPACT services during the year. Association between V-IMPACT adoption and outcomes were assessed using mixed-effects models. Results: V-IMPACT adoption was associated with increased telehealth visits for PC (incidence rate ratio [IRR] = 2.42 [1.29 to 4.55]) and for primary care mental health integration (IRR = 7.25 [2.69 to 19.54]). V-IMPACT adoption was not associated with in-person visits, or with total visits (in-person plus video telehealth). V-IMPACT adoption was also not associated with acute hospital stays, emergency department visits, or VHA costs. Conclusions: Programs such as VHA's V-IMPACT can increase telehealth visits for PC, allowing successful transition across modalities and facilitating continuity of care without impacting total care. Programs should track substitution of in-person visits with telehealth visits and examine its effects on patients' health outcomes, satisfaction, and travel costs.

Impulsivity and Medical Care Utilization in Veterans Treated for Substance Use Disorder.

BACKGROUND: Impulsivity has been defined by acting rashly during positive mood states (positive urgency; PU) or negative mood states (negative urgency; NU) and by excessive de-valuation of deferred rewards. These behaviors reflect a "live in the now" mentality that is not only characteristic of many individuals with severe substance use disorder (SUD) but also impedes medical treatment compliance and could result in repeated hospitalizations or other poor health outcomes. Purpose/objectives: We sought preliminary evidence that impulsivity may relate to adverse health outcomes in the veteran population. Impulsivity measured in 90 veterans receiving inpatient or outpatient SUD care at a Veterans Affairs Medical Center was related to histories of inpatient/residential care costs, based on VA Health Economics Resource Center data. Results: We found that positive urgency, lack of persistence and lack of premeditation, but not sensation-seeking or preference for immediate or risky rewards, were significantly higher in veterans with a history of one or more admissions for VA-based inpatient or residential health care that either included (n = 30) or did not include (n = 29) an admission for SUD care. Among veterans with a history of inpatient/residential care for SUD, NU and PU, but not decision-making behavior, correlated with SUD care-related costs. Conclusions/Importance: In veterans receiving SUD care, questionnaire-assessed trait impulsivity (but not decision-making) related to greater care utilization within the VA system. This suggests that veterans with high impulsivity are at greater risk for adverse health outcomes, such that expansion of cognitive interventions to reduce impulsivity may improve their health.

Barriers and Facilitators to Employment: A Comparison of Participants With Multiple Sclerosis and Spinal Cord Injury.

OBJECTIVE: To compare self-reported barriers and facilitators to employment among employed and unemployed participants with multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Cross-sectional study using self-report assessment obtained by mail or online. SETTING: Medical university in the southeastern United States. PARTICIPANTS: Participants (N=2624) identified from either a specialty hospital or a state-based surveillance system in the southeastern United States, including 1234 with MS and 1390 with SCI. All participants were aged <65 years at the time of assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported barriers and facilitators to employment. RESULTS: Overall, the MS participants reported more barriers, particularly stress, cognition, and fatigue, whereas those with SCI were more likely to report not having the proper education and training, resources, transportation, and attendant care. Follow-up analyses broken down by employment status indicated that several barriers and facilitators were significantly related to diagnosis for either employed or unemployed participants, but not both. Among those employed, participants with SCI were more likely to report they could not do the same types of jobs as they could pre-SCI and those with MS were more likely to state that they did not know much about jobs for people with disabilities (no differences were noted for these variables among unemployed participants). Unemployed individuals with SCI were more likely to report that the jobs for which they were trained were not accessible. CONCLUSIONS: The primary barriers for individuals with MS revolve around the condition itself, whereas the barriers for SCI appear to be more related to modifiable factors. Vocational rehabilitation specialists need to identify diagnostic-specific barriers to promote employment outcomes.

Cost-effectiveness of financial incentives to improve glycemic control in adults with diabetes: A pilot randomized controlled trial.

PURPOSE: Determine the cost-effectiveness of three financial incentive structures in obtaining a 1% within group drop in HbA1c among adults with diabetes. METHODS: 60 African Americans with type 2 diabetes were randomized to one of three financial incentive structures and followed for 3-months. Group 1 (low frequency) received a single incentive for absolute HbA1c reduction, Group 2 (moderate frequency) received a two-part incentive for home testing of glucose and absolute HbA1c reduction and Group 3 (high frequency) received a multiple component incentive for home testing, attendance of weekly telephone education classes and absolute HbA1c reduction. The primary clinical outcome was HbA1c reduction within each arm at 3-months. Cost for each arm was calculated based on the cost of the intervention, cost of health care visits during the 3-month time frame, and cost of workdays missed from illness. Incremental cost effectiveness ratios (ICER) were calculated based on achieving a 1% within group drop in HbA1c and were bootstrapped with 1,000 replications. RESULTS: The ICER to decrease HbA1c by 1% was $1,100 for all three arms, however, bootstrapped standard errors differed with Group 1 having twice the variation around the ICER coefficient as Groups 2 and 3. ICERs were statistically significant for Groups 2 and 3 (p<0.001) indicating they are cost effective interventions. CONCLUSIONS: Given ICERs of prior diabetes interventions range from $1,000-$4,000, a cost of $1,100 per 1% within group decrease in HbA1c is a promising intervention. Multi-component incentive structures seem to have the least variation in cost-effectiveness.

Lowering the impact of food insecurity in African American adults with type 2 diabetes mellitus (LIFT-DM) - Study protocol for a randomized controlled trial.

BACKGROUND: There is strong evidence that disparities in the burden of diabetes exist by both race and poverty. Food insecurity, or an inability to or limitation in accessing nutritionally adequate food, is an important modifiable social determinant of health, particularly in adults with chronic disease. African Americans are more likely to be diagnosed with diabetes and more likely than whites to be food insecure. METHODS: We describe a 4-year ongoing randomized controlled trial, which will test the separate and combined efficacy of monthly food vouchers and monthly food stock boxes layered upon diabetes education in improving glycemic control in low income, food insecure, African Americans with type 2 diabetes mellitus using a 2 × 2 factorial design. Three hundred African American adults with clinical diagnosis of diabetes and HbA1c ≥ 8% will be randomized into one of four groups: 1) diabetes education alone; 2) diabetes education plus food vouchers; 3) diabetes education plus stock boxes; and 4) diabetes education plus combined food vouchers and stock boxes. Our primary hypothesis is: among low-income, food insecure, African Americans with type 2 diabetes, those receiving diabetes education enhanced with food supplementation (food vouchers alone, stock boxes alone, or combination) will have significantly greater reduction in HbA1c at 12 months compared to those receiving diabetes education only. DISCUSSION: Results from this study will yield valuable insight currently lacking on how best to design and deliver diabetes interventions to low-income, food insecure, African Americans with diabetes that takes into account both clinical and social determinants of health. TRIAL REGISTRATION: This study was registered on November 29, 2019 with the United States National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT04181424).

Cost-Benefit Analysis From the Payor's Perspective for Screening and Diagnosing Obstructive Sleep Apnea During Inpatient Rehabilitation for Moderate to Severe TBI.

OBJECTIVE: To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective. DESIGN: A cost-benefit analysis of phased approaches to sleep apnea diagnosis. SETTING: Six TBI Model System Inpatient Rehabilitation Centers. PARTICIPANTS: Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). INTERVENTION: Not applicable. MAIN OUTCOME: Cost benefit. RESULTS: At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness. CONCLUSIONS: The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

Impact of the Affordable Care Act Medicaid Expansion on Access to Care and Hospitalization Charges for Lupus Patients.

OBJECTIVE: To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion. METHODS: A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition. RESULTS: There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges. CONCLUSION: Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.

Employment status, hours working, and gainful earnings after spinal cord injury: relationship with pain, prescription medications for pain, and nonprescription opioid use.

STUDY DESIGN: Cross-sectional self-report assessment. Econometric modeling. OBJECTIVES: Identify the relationship of multiple pain indicators, prescription pain medication, nonprescription opioid use, and multiple indicators of quality employment among those with spinal cord injury (SCI). SETTING: Data were collected at a medical university in the Southeastern United States (US). METHODS: Participants included 4670 adults with traumatic SCI of at least one-year duration who were enrolled in a study of health and longevity. They were identified from three sources including a specialty hospital and two population-based state SCI surveillance systems. Econometric modeling was used for three outcome variables: employment status, hours per week spent working, and earnings. RESULTS: Several pain parameters were significantly related to multiple employment outcomes. Prescription medication to treat pain was associated with lower odds of employment, fewer hours working, and lower conditional earnings. Nonprescription opioid use was only related to fewer hours working. Painful days, number of painful conditions, and pain intensity were all related to employment outcomes, but the pattern varied by outcome. The number of painful conditions was most consistently related to employment. Multiple demographic, injury, and educational factors were related to employment, with better outcomes among those with less severe SCI and greater educational achievements. CONCLUSIONS: The presence of significant pain and use of either prescription pain medications or the use of nonprescription opioids may have a significant adverse effect on both the probability of employment and quality of employment. Rehabilitation and vocational professionals should routinely assess pain and associated medications in vocational and career planning.