Postacute stroke rehabilitation utilization: are there differences between rural-urban patients and taxonomies?

PURPOSE: To assess the association between Veterans affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. METHODS: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received 12-months poststroke hospitalization. Patients' urban, rural, or isolated/highly rural status was determined using the rural-urban commuting areas (RUCA) and VA rural urban (VARU) definitions based on patient residential ZIP code. Logistic regression models were fit for the rehabilitation outcome, adjusting for potential risk factors. FINDINGS: Among the 8,296 stroke patients, 69.6%/61.1% were categorized as urban, 21.3%/37.5% as rural, and 9.1%/1.4% as isolated/highly rural by the RUCA/VARU definitions, respectively. Compared with their urban counterparts, the rural and/or isolated/highly rural patients were significantly more likely to be older, white, married, living further from the VA hospitals, not hospitalized for stroke directly from home, and not intubated. Compared with the rural patients, odds of receiving rehabilitation therapy were 1.2 times (RUCA) and 1.1 times (VARU) by the urban patients, and 0.53 times (VARU only) by the highly rural patients, after risk adjustment. The above comparisons were significant at P < .05. CONCLUSIONS: With both taxonomies, the rural patients were less likely to receive postacute stroke rehabilitant therapy than their urban counterparts. With the VARU, the highly rural patients were less likely to receive rehabilitation care than their rural counterparts. Different taxonomy may lead to different rural-urban classification yields and different yields may lead to different outcomes and conclusions.

Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?

OBJECTIVES: To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures--the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)--in how well they predict these outcomes. DESIGN: Inception cohort of patients followed for 6 months. SETTING: Department of Veterans Affairs (VA) hospitals. PARTICIPANTS: A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score. RESULTS: During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R(2) values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R(2) of .111 for change in FIM score. CONCLUSIONS: Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.

A mixed integer programming model to locate traumatic brain injury treatment units in the Department of Veterans Affairs: a case study.

For the Department of Veterans Affairs (VA), traumatic brain injury (TBI) is a significant problem facing active duty military personnel, veterans, their families, and caregivers. The VA has designated TBI treatment as one of its physical medicine and rehabilitation special emphasis programs, thereby providing a comprehensive array of treatment services to those military personnel and veterans with TBI. Timely treatment of TBI is critical in achieving maximal recovery, and being in geographical proximity to a medical center with specialized TBI treatment services is a major determinant of whether such treatment is utilized. We present a mixed integer programming model for locating TBI treatment units in the VA. This model was developed for the VA Rehabilitation Strategic Healthcare Group to assist in locating new TBI treatment units. The optimization model assigns TBI treatment units to existing VA medical centers while minimizing the sum of patient treatment costs, patient lodging and travel costs, and the penalty costs associated with foregone treatment revenue and excess capacity utilization. We demonstrate our model with VA TBI admission data from one of the VA's integrated service networks, and discuss the expected service and cost implications for a range of TBI treatment unit location options.

Multiple system utilization and mortality for veterans with stroke.

BACKGROUND AND PURPOSE: Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. METHODS: Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. RESULTS: The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). CONCLUSIONS: Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Race/ethnicity: who is counting what?

Misclassification of race and ethnicity in administrative data may produce misleading results if it is overlooked or ignored. In this study, we examined the racial/ethnic classifications of 1,084 veterans with stroke in Florida who received inpatient and outpatient services within the Department of Veterans Affairs (VA) healthcare system and who were also eligible for Medicare between 2000 and 2001. We compared the reliability of racial/ethnic classifications between VA inpatient data, VA outpatient data, and Medicare data. Our results showed that (1) the rate of unknown racial/ethnic classification in VA outpatient and inpatient data was high, (2) minimizing the unknowns by substituting known values from other data when available would greatly enhance the overall and individual classification reliability, (3) black and white classifications in the VA data had stronger agreement with Medicare data, and (4) Medicare data may under-represent Hispanic patients.

The association between in-service sexual harassment and post-traumatic stress disorder among Department of Veterans Affairs disability applicants.

OBJECTIVE: The goal was to describe the association between post-traumatic stress disorder (PTSD) and in-service sexual harassment in a nationally representative sample of Department of Veterans Affairs PTSD disability applicants. METHOD: The study was a cross-sectional survey. RESULTS: Of 4,918 eligible veterans, 3,337 (68%) returned surveys. Nonresponse bias appeared to be minimal. After adjustment for other reported traumas, women's reported in-service sexual harassment severity was significantly associated with PTSD symptom severity (p < 0.0001). The effect seen was about the same size as that seen for combat exposure among the men and for in-service sexual assault among the women. Men showed no association between in-service sexual harassment and PTSD (p = 0.33), although power was low for this test. CONCLUSION: Sexual harassment significantly contributed to female veterans' PTSD symptoms; its contribution to men's symptoms was unclear. We discuss mechanisms through which sexual harassment might affect PTSD symptom severity, including the possibility that sexual harassment sometimes meets the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, definition of a criterion A stressor.

Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income.

OBJECTIVE: The goal was to assess the impact of Veterans Affairs (VA) disability benefits for post-traumatic stress disorder (PTSD) on veterans' odds of poverty. Women and African American veterans were of special interest, because they are less likely than other groups to receive PTSD disability benefits. METHODS: A cross-sectional survey of 4,918 veterans who applied for VA disability benefits for PTSD between 1994 and 1998 was performed. Responses were linked to administrative data. RESULTS: Overall, 42% reported low income (defined as household income less than or equal to 20,000 dollars per year). Men's and women's odds of reporting poverty were similar, but receipt of PTSD disability benefits mediated African American veterans' odds of poverty. Veterans' odds of impoverishment were reduced considerably if they received VA PTSD disability benefits and identified themselves as disabled. CONCLUSIONS: VA disability benefits for PTSD reduced odds of impoverishment for psychiatrically ill veterans. This effect appeared to be especially important for African American veterans and for veterans self-identifying as disabled.

Development of an integrated stroke outcomes database within Veterans Health Administration.

A fundamental goal of the Rehabilitation Outcomes Research Center of Excellence is to improve care and outcomes for veterans with rehabilitation needs. To achieve this goal, the Center's primary objective is increasing research capacity. The Integrated Stroke Outcomes Database is a collection of Veterans Health Administration (VHA) clinical and administrative data containing patient information on a cohort of stroke patients found in the Functional Status Outcomes Database (FSOD), National Patient Care Database (NPCD), and other VHA sources. Clinical and administrative data were abstracted from several VHA data sources and linked to form an integrated outcomes database. A primary cohort of stroke patients treated during fiscal year (FY) 2001 was identified from the FSOD. Matching data from the NPCD, Decision Support System, Health Economics Resource Center, and the National Veterans Survey were obtained, merged, and reported in brief. This integrated database structure will provide valuable support to enhance the VHA capacity to perform stroke rehabilitation research.

Regional variation and other correlates of Department of Veterans Affairs Disability Awards for patients with posttraumatic stress disorder.

BACKGROUND: Minnesota, Minneapolis, Minnesota. Posttraumatic stress disorder (PTSD) is a chronic disabling condition affecting more than 600,000 United States veterans and is the most common psychiatric condition for which veterans seek Veterans Affairs disability benefits. Receipt of such benefits enhances veterans' access to Veteran Affairs health care and reduces their chance of poverty. OBJECTIVES: We sought to determine whether previously identified regional variations in PTSD disability awards are explained by appropriate subject characteristics (eg, differences in PTSD symptomatology or dysfunction) and to estimate the impact of veterans' PTSD symptom severity or level of dysfunction on their odds of obtaining PTSD disability benefits. RESEARCH DESIGN: We used a mailed survey linked to administrative data. SUBJECTS: Subjects included 4918 representative, eligible men and women who filed PTSD disability claims between 1994 and 1998. RESULTS: A total of 3337 veterans returned useable surveys (68%). Before adjustment, PTSD disability claims approval rates ranged from 43% to 75% across regions. After adjustment, rates ranged from 33% to 72% (P <0.0001). Severer PTSD symptoms were associated with greater odds of having PTSD disability benefits (P <0.0001). Unexpectedly, poorer functional status was associated with lower odds of having benefits (P <0.0001). On average, clinical differences between veterans who did and did not have PTSD disability benefits were small but suggested slightly greater dysfunction among those without benefits. CONCLUSIONS: An almost twofold regional difference in claims approval rates was not explained by veterans' PTSD symptom severity, level of dysfunction, or other subject-level characteristics. Veterans who did not obtain PTSD disability benefits were at least as disabled as those who did receive benefits.

Using GIS in government: an overview of the VHA's Healthcare Atlas, FY-2000.

The amount of VA data available for analysis can be overwhelming to individuals who need to translate these data into usable information. The Atlas, using current GIS technology, was funded to provide data in a comprehensive guide. Patients were identified using a disease classification scheme based on Kaiser Permanente methodology and the Clinical Classifications Software (AHRQ). Utilization data were extracted from the Medical SAS Datasets. Cost data were obtained from the HERC. GIS tools were used to create the Atlas. The Atlas overviews the location of VA hospitals; profiles veteran, VA enrollee and patient populations; examines overall utilization; depicts patterns in healthcare use by specific disease cohorts; and examines geographic variations in costs. This product will enhance knowledge of VA's enrolled patient population and their healthcare needs, and provide background information that will improve the formulation of specific research questions to address those needs.

Using GIS to profile health-care costs of VA Quality-Enhancement Research Initiative diseases.

The Health Services Research and Development (HSR&D) Service at the Department of Veterans Affairs (VA) Health Care System launched a Quality Enhancement Research Initiative (QUERI) in 1998. This study estimated health-care costs of nine diseases under the QUERI project and analyzed geographic differences in health-care costs and utilization across 22 VA Integrated Service Networks (VISNs), using a geographic information system (GIS). Patients with these diseases were identified from diagnoses recorded between October 1999 and September 2000. Annual health-care costs for each disease were estimated in four categories: inpatient medical or surgical, other inpatient, outpatient, and outpatient pharmacy. Geographic differences of costs and health-care utilization across the 22 VISNs for chronic heart failure, diabetes, and spinal-cord injury were mapped using a GIS package. Average costs and patterns of health-care utilization varied substantially across the 22 VISNs. The observed differences in health-care utilization across geographic regions raised questions for further investigation.

Analyses of male residents in community nursing facilities: comparisons of Veterans Health Administration residents to other residents.

We compared Veterans Health Administration (VHA) residents in community nursing facilities to other residents. We used all admission assessments in the Minimum Data Set throughout the United States during 2000 to identify 7,296 male VHA residents and 159,203 other male residents in community nursing facilities. Male VHA residents were significantly more independent in the self-performance of activities of daily living and less physically disabled than other male residents, with minor differences in cognitive function as measured by a Cognitive Performance Scale. Male VHA residents were more likely to have comorbidities than other male residents. Significantly larger proportions of other male residents than VHA residents received special treatments and procedures, with especially large differences for various therapies (e.g., physical therapy). We found significant differences in the demographic and clinical characteristics of male VHA residents in community nursing facilities compared with other male residents. These differences in the delivery of services may have implications for the quality of care for veterans in this setting.

Gender Differences in service connection for PTSD.

BACKGROUND: Mentally ill female veterans obtain a smaller proportion of their care from Department of Veterans Affairs (VA) facilities than mentally ill male veterans do, possibly because women are less likely than men to be service connected for psychiatric disabilities. "Service connected" veterans have documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the VA healthcare system. OBJECTIVES: To see if there are gender discrepancies in rates of service connection for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could be attributed to appropriate subject characteristics (eg, differences in symptom severity or impairment). RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SUBJECTS: Randomly selected veterans seeking VA disability benefits for PTSD. Women were oversampled to achieve a gender ratio of 1:1. RESULTS: A total of 3337 veterans returned usable surveys (effective response rate, 68%). Men's unadjusted rate of service connection for PTSD was 71%; women's, 52% (P < 0.0001). Adjustment for veterans' PTSD symptom severity or functional impairment did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of combat exposure did. Estimated rates of service connection were 53% for men and 56% for women after adjusting for combat exposure. This combat preference could not be explained by more severe PTSD symptoms or greater functional impairment. CONCLUSIONS: Instead of a gender bias in awards for PTSD service connection, we found evidence of a combat advantage that disproportionately favored men. The appropriateness of this apparent advantage is unclear and needs further investigation.

Racial disparities in VA service connection for posttraumatic stress disorder disability.

BACKGROUND: "Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. OBJECTIVES: To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SETTING AND SUBJECTS: The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. RESULTS: A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). CONCLUSION: Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.

A primer and comparative review of major US mortality databases.

PURPOSE: Mortality data are important tools for research requiring vital status information. We reviewed the major mortality databases and mortality ascertainment services available in the United States, including the National Death Index (NDI), the Social Security Administration (SSA) files, and the Department of Veterans Affairs databases. METHODS: The content, reliability, and accuracy of mortality sources are described and compared. We also describe how investigators can gain access to these resources and provide further contact information. RESULTS: We reviewed the accuracy of major mortality sources. The sensitivity (i.e., the proportion of the true number of deaths) of the NDI ranged from 87.0% to 97.9%, whereas the sensitivity for the VA Beneficiary Identification and Records Locator System (BIRLS) ranged between 80.0% and 94.5%. The sensitivity of SSA files ranged between 83.0% and 83.6%. Sensitivity for the VA Patient Treatment File (PTF) was 33%. CONCLUSIONS: While several national mortality ascertainment services are available for vital status (i.e., death) analyses, the NDI information demonstrated the highest sensitivity and, currently, it is the only source at the national level with a cause of death field useful for research purposes. Researchers must consider methods used to ascertain vital status as well as the quality of the information in mortality databases.