Gender differences in VA disability status for PTSD over time.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is the most prevalent psychiatric condition for which veterans receive service-connected disability benefits from the U.S. Department of Veterans Affairs (VA). Historically, women have been less likely than men to obtain PTSD disability benefits. The authors examined whether these gender disparities have been redressed over time and, if not, whether appropriate clinical factors account for persisting differences. METHODS: This longitudinal, observational study was based on a gender-stratified, nationally representative sample of 2,998 U.S. veterans who applied for VA disability benefits for PTSD between 1994 and 1998. The primary outcome was change in PTSD service connection over a ten-year period. RESULTS: Forty-two percent (95% confidence interval [CI]=38%-45%) of the women and 50% (CI=45%-55%) of the men originally denied service connection for PTSD eventually received such benefits. Only 8% (CI=7%-10%) of women and 5% (CI=4%-6%) of men lost PTSD disability status. Compared with men, women had lower unadjusted odds of gaining PTSD service connection (odds ratio [OR]=.70, CI=.55-.90) and greater unadjusted odds of losing PTSD service connection (OR=1.76, CI=1.21-2.57). Adjusting for clinical factors accounted for the gender difference in gaining PTSD service connection; adjusting for clinical factors and demographic characteristics eliminated the gender difference in loss of PTSD service connection. CONCLUSIONS: Gender-based differences in receipt of PTSD service connection persisted in this cohort over a ten-year period but were explained by appropriate sources of variation. Further research on possible disparities in loss of PTSD disability benefits is warranted.

Headache diagnoses among Iraq and Afghanistan war veterans enrolled in VA: a gender comparison.

OBJECTIVE: To examine the prevalence and correlates of headache diagnoses, by gender, among Iraq and Afghanistan War Veterans who use Department of Veterans Affairs (VA) health care. BACKGROUND: Understanding the health care needs of recent Veterans, and how these needs differ between women and men, is a priority for the VA. The potential for a large burden of headache disorders among Veterans seeking VA services exists but has not been examined in a representative sample. METHODS: We conducted a historical cohort study using national VA inpatient and outpatient data from fiscal year 2011. Participants were all (n = 470,215) Iraq and Afghanistan War Veteran VA users in 2011; nearly 13% were women. We identified headache diagnoses using International Classification of Diseases (ICD-9) diagnosis codes assigned during one or more VA inpatient or outpatient encounters. Descriptive analyses included frequencies of patient characteristics, prevalence and types of headache diagnoses, and prevalence of comorbid diagnoses. Prevalence ratios (PR) with 95% confidence intervals (CI) were used to estimate associations between gender and headache diagnoses. Multivariate models adjusted for age and race. Additional models also adjusted for comorbid diagnoses. RESULTS: In 2011, 56,300 (11.9%) Veterans received a headache-related diagnosis. While controlling for age and race, headache diagnoses were 1.61 times more prevalent (95% CI = 1.58-1.64) among women (18%) than men (11%). Most of this difference was associated with migraine diagnoses, which were 2.66 times more prevalent (95% CI = 2.59-2.73) among women. Cluster and post-traumatic headache diagnoses were less prevalent in women than in men. These patterns remained the same when also controlling for comorbid diagnoses, which were common among both women and men with headache diagnoses. The most prevalent comorbid diagnoses examined were depression (46% of women with headache diagnoses vs 40% of men), post-traumatic stress disorder (38% vs 58%), and back pain (38% vs 46%). CONCLUSIONS: Results of this study have implications for the delivery of post-deployment health services to Iraq and Afghanistan War Veterans. Migraine and other headache diagnoses are common among Veterans, particularly women, and tend to occur in combination with other post-deployment health conditions for which patients are being treated.

Sensitivity and specificity of traumatic brain injury diagnosis codes in United States Department of Veterans Affairs administrative data.

OBJECTIVE: To examine the validity of using International Classification of Diseases (ICD) diagnosis codes from United States Department of Veterans Affairs (VA) data to describe prevalence of traumatic brain injury (TBI) among military veterans. METHODS: VA clinicians complete a standardized TBI evaluation to determine whether veterans' deployment exposures resulted in TBI. Clinician-confirmed cases and non-cases of TBI were used as recorded on the evaluation as the criterion standard against which to evaluate three series of TBI-related ICD diagnosis codes in national VA datasets. Focusing on codes used within VA, measures of validity were calculated and correlates of discordance examined, including patient characteristics, region and time. Secondarily, it was examined whether TBI codes can differentiate mild from more severe TBI cases. RESULTS: Of 49 962 veterans with completed TBI evaluations, 29 534 (59%) received clinician-confirmed TBI diagnoses. Sensitivity of the VA series of codes was 70%, specificity was 82% and concordance was 75%. Concordance varied by region, but not by patient characteristics or time. Codes were not useful for distinguishing mild TBI. CONCLUSION: Estimates of TBI prevalence in military veterans are important for national programme development and resource distribution. Estimates derived from ICD diagnosis codes in administrative data should take potential misclassification into account.

Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran V.A. 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 ($5831 vs. $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 ($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.

Long-term outcomes of disability benefits in US veterans with posttraumatic stress disorder.

CONTEXT: Most studies examining the clinical impact of disability benefits have compared aid recipients with people who never applied for benefits. Such practices may bias findings against recipients because disability applicants tend to be much sicker than never-applicants. Furthermore, these studies ignore the outcomes of denied claimants. OBJECTIVE: To examine long-term outcomes associated with receiving or not receiving Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD), the most common mental disorder for which veterans seek such benefits. DESIGN: Comparison of outcomes between successful and unsuccessful applicants for VA disability payments. Because we could not randomize the receipt of benefits, we used exact matching by propensity scores to control for potential baseline differences. We examined clinical outcomes approximately 10 years later. SETTING AND PARTICIPANTS: Stratified, nationally representative cohort of 3337 veterans who applied for VA PTSD disability benefits between January 1, 1994, and December 31, 1998. MAIN OUTCOME MEASURES: Assessment on validated survey measures of PTSD; work, role, social, and physical functioning; employment; and poverty. We compared outcomes with earlier scores. Homelessness and mortality were assessed using administrative data. RESULTS: Of still-living cohort members, 85.1% returned usable surveys. Symptoms of PTSD were elevated in both groups. After adjustment, awardees had more severe PTSD symptoms than denied claimants but were nonetheless more likely to have had a meaningful symptom reduction since their last assessment (-6.1 vs -4.4; SE, 0.1; P = .01). Both groups had meaningful improvements of similar magnitude in work, role, and social functioning (-0.15 vs -0.19; SE, 0.01; P = .94), but functioning remained poor nonetheless. Comparing awardees with denied claimants after adjustment, 13.2% vs 19.0% were employed (P = .11); 15.2% vs 44.8% reported poverty (P < .001); 12.0% vs 20.0% had been homeless (P = .02); and 10.4% vs 9.7% had died (P = .66). CONCLUSIONS: Regardless of claim outcome, veterans who apply for PTSD disability benefits are highly impaired. However, receiving PTSD benefits was associated with clinically meaningful reductions in PTSD symptoms and less poverty and homelessness.

Improving endoscopy completion: effectiveness of an interactive voice response system.

OBJECTIVE: To test whether an interactive voice response (IVR) system phone call was equally effective as a nurse-delivered phone call at educating and preparing patients for flexible sigmoidoscopy (FS) and colonoscopy examinations. STUDY DESIGN: Three-arm randomized controlled trial. METHODS: The trial included patients with upcoming FS or colonoscopy appointments to test the equivalence of an IVR system to nurse-delivered phone calls in reducing appointment nonattendance and inadequate preparation for an examination. Message timing and satisfaction with the intervention were assessed. The 3 study conditions included the following: nurse phone call 7 days before the procedure, IVR system call 7 days before the procedure, and IVR system call 3 days before the procedure. All calls included an appointment reminder, information about preparation for the examination, and encouragement to prepare for and attend the examination. RESULTS: A total of 3610 patients were eligible for the study; of these, 1229 (34%) were scheduled for FS and 2381 (66%) for colonoscopy. There were no statistically significant differences across the 3 study arms in appointment attendance or adherence to preparation instructions. Significantly more patients in IVR conditions reported neutral perceptions about the phone calls, and more patients receiving nurse calls reported very positive perceptions about the phone calls. CONCLUSION: An IVR system call is as effective as a nurse phone call for ensuring that patients attend appointments and are adequately prepared for endoscopy examinations.

Teledermatology for diagnosis and management of skin conditions: a systematic review.

OBJECTIVE: We performed a systematic review of the literature addressing teledermatology: (1) diagnostic accuracy/concordance; (2) management accuracy/concordance; (3) clinical outcomes; and (4) costs. METHODS: Peer-reviewed controlled trials published in English between 1990 and 2009 were identified through MEDLINE and PubMed searches. RESULTS: Of 78 included studies, approximately two-thirds comparing teledermatology and clinic dermatology found better diagnostic accuracy with clinic dermatology. Diagnostic concordance of store and forward with clinic dermatology was good; concordance rates for live interactive and clinic dermatology were higher, but based on fewer patients. Overall rates of management accuracy were equivalent, but teledermatology and teledermatoscopy were inferior to clinic dermatology for malignant lesions. Management concordance was fair to excellent. There was insufficient evidence to evaluate clinical course outcomes. Patient satisfaction and preferences were comparable. Teledermatology reduced time to treatment and clinic visits and was cost-effective if certain assumptions were met. LIMITATIONS: Heterogeneity in studies (design, skin conditions, outcomes) limited the ability to pool data. CONCLUSION: The benefits of teledermatology need to be evaluated in the context of potential limitations.