Douglas E. Bidelspach

Prevalence and Costs of Co-occurring Traumatic Brain Injury With and Without Psychiatric Disturbance and Pain Among Afghanistan and Iraq War Veteran VA Users

Background:Traumatic brain injury (TBI) is the “signature injury” in the Afghanistan and Iraq wars [Operation Enduring Freedom in Afghanistan (OEF)/Operation Iraqi Freedom (OIF)]. Patients with combat-related TBI also have high rates of psychiatric disturbances and pain. Objectives:To determine the prevalence of TBI alone and TBI with other conditions and the average cost of medical care for veterans with these diagnoses. Methods:Observational study using national inpatient, outpatient, and pharmacy data from Veterans Health Administration (VHA) datasets. Costs are estimated from utilization related to care within the VHA system. Participants were all OEF/OIF VHA users in 2009. Results:Among 327,388 OEF/OIF veterans using VHA services in 2009, 6.7% were diagnosed with TBI. Among those with TBI diagnoses, 89% were diagnosed with a psychiatric diagnosis [the most frequent being posttraumatic stress disorder (PTSD) at 73%], and 70% had a diagnosis of head, back, or neck pain. The rate of comorbid PTSD and pain among those with and without TBI was 54% and 11%, respectively. The median annual cost per patient was nearly 4-times higher for TBI-diagnosed veterans as compared with those without TBI (

Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans.

5831 vs.

Prognostic Differences for Functional Recovery After Major Lower Limb Amputation: Effects of the Timing and Type of Inpatient Rehabilitation Services in the Veterans Health Administration

1547). Within the TBI group, cost increased as diagnostic complexity increased, such that those with TBI, pain, and PTSD demonstrated the highest median cost per patient (

Survival Analysis in Amputees Based on Physical Independence Grade Achievement

7974). Conclusions:The vast majority of VHA patients diagnosed with TBI also have a diagnosed mental disorder and more than half have both PTSD and pain. Patients with these comorbidities incur substantial medical costs and represent a target population for future research aimed at improving health care efficiency.

Development of a traumatic brain injury model system within the Department of Veterans Affairs Polytrauma System of Care.

To identify the prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain in Veterans from Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND), Veterans who received any inpatient or outpatient care from Veterans Health Administration (VHA) facilities from 2009 to 2011 were studied. A subset of Veterans was identified who were diagnosed with TBI, PTSD, and/or pain (head, neck, or back) as determined by their International Classification of Diseases-9th Revision-Clinical Modification codes. Between fiscal years 2009 and 2011, 613,391 Veterans accessed VHA services at least once (age: 31.9 +/- 9.6 yr). TBI diagnosis in any 1 year was slightly less than 7%. When data from 3 years were pooled, 9.6% were diagnosed with TBI, 29.3% were diagnosed with PTSD, and 40.2% were diagnosed with pain. The full polytrauma triad expression (TBI, PTSD, and pain) was diagnosed in 6.0%. Results show that increasing numbers of Veterans from OIF/OEF/OND accessed VHA over a 3 year period. Among those with a TBI diagnosis, the majority also had a mental health disorder, with approximately half having both PTSD and pain. While the absolute number of Veterans increased by over 40% from 2009 to 2011, the proportion of Veterans diagnosed with TBI and the high rate of comorbid PTSD and pain in this population remained relatively stable.

Possible Incremental Benefits of Specialized Rehabilitation Bed Units Among Veterans After Lower Extremity Amputation

To compare the recovery of mobility and self‐care functions among veteran amputees according to the timing and type of rehabilitation services received.

Factors Influencing Decisions to Admit Patients to Veterans Affairs Specialized Rehabilitation Units After Lower-Extremity Amputation

BACKGROUND Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE Cumulative 6-month survival after rehabilitation discharge. RESULTS The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

SHORT- AND LONG-TERM PROGNOSIS AMONG VETERANS WITH NEUROLOGICAL DISORDERS AND SUBSEQUENT LOWER-EXTREMITY AMPUTATION

Background:In 2008, the Department of Veterans Affairs Polytrauma Rehabilitation Centers partnered with the National Institute on Disability and Rehabilitation Research to establish a Model Systems program of research that would closely emulate the civilian Traumatic Brain Injury (TBI) Model Systems Centers Program established in 1987. Objective:To describe the development of a TBI Model Systems program within the Department of Veterans Affairs Polytrauma System of Care. Methods:Enrollment criteria and data collection/data quality efforts for the newly established Department of Veterans Affairs sites are reviewed. Results:Significant progress has been made in the establishment of a Model Systems program for the Polytrauma System of Care. Data collection has moved forward and program-specific modifications have been implemented. Conclusion:The Veterans Affairs TBI Model System program is established and growing, with many projects underway and a strong working relationship with the civilian TBI Model System programs.

Poststroke Rehabilitation and Restorative Care Utilization: A Comparison Between VA Community Living Centers and VA-contracted Community Nursing Homes.

Background:Little is known about the effect of different types of inpatient rehabilitation on outcomes of patients undergoing lower extremity amputation for nontraumatic reasons. Objective:To compare outcomes between patients who received inpatient rehabilitation on specific rehabilitation bed units (specialized) to patients who received rehabilitation on general medical/surgical units (generalized) during the acute postoperative period. Methods:This was an observational study including 1339 veterans who underwent lower extremity amputation between October 1, 2002 and September 30, 2004. Data were compiled from 9 administrative databases from the Veterans Health Administration. Propensity score risk adjustment methodology was used to reduce selection bias in looking at the effect of type of rehabilitation on outcomes (1-year survival, home discharge from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge). Results:After applying propensity score risk adjustment, there was strong evidence that patients who received specialized versus generalized rehabilitation were more likely to be discharged home (risk difference = 0.10), receive a prescription for a prosthetic limb (risk difference = 0.13), and improve physical functioning (gains on average 6.2 points higher). Specialized patients had higher 1-year survival (risk difference = 0.05), but the difference was not statistically significant. The sensitivity analysis demonstrated our findings to be unaffected by a moderately strong amount of unmeasured confounding. Conclusions:Receipt of specialized compared with generalized rehabilitation during the acute postoperative inpatient period was associated with better outcomes. Future studies will need to look at different intensity, timing, and location of rehabilitation services.

Regional variation in post-stroke multidisciplinary rehabilitation care among veteran residents in community nursing homes

UNLABELLED Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN Database study. SETTING All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Admission to an SRU. RESULTS There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.