Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI

Abstract

Objective:Primary: To examine Veterans Administration (VA) utilization and other potential mediators between racial/ethnic differentials and mortality in veterans diagnosed with traumatic brain injury (TBI).Design:A national cohort of veterans clinically diagnosed with TBI in 2006 was followed from January 1, 2006 through December 31, 2009 or until date of death. Utilization was tracked for 12 months. Differences in survival and potential mediators by race were examined via K-Wallis and chi-square tests. Potential mediation of utilization in the association between mortality and race/ethnicity was studied by fitting Cox models with and without adjustment for demographics and co-morbidities. Poisson regression was used to study the association of race/ethnicity with utilization of specialty services potentially important in the management of TBI.Setting:United States (US) Veterans Administration (VA) Hospitals and Clinics.Participants:14, 690 US veterans clinically diagnosed with TBI in 2006.Interventions:Not Applicable. The study is a secondary data analysis.Main Outcome Measures:Mortality, Utilization.Results:Hispanic veterans were found to have significantly higher unadjusted mortality (6.69%) than Non-Hispanic White veterans (2.93%). Hispanic veterans relative to Non-Hispanic White were found to have significantly lower utilization of all services examined, except imaging. Neurology was found to be the utilization mediator with the highest percent of excess risk (3.40%) while age was the non utilization confounder with the highest percent of excess risk (31.49%). In fully adjusted models for demographics and co-morbidities, Hispanic veterans relative to Non-Hispanic Whites were found to have less total visits (IRR 0.89), TBI clinic (IRR 0.43), neurology (IRR 0.35), rehabilitation (IRR 0.37), and other visits (IRR 0.85) with only higher mental health visits (IRR 1.53).Conclusions:We found evidence that utilization is a partial mediator between race/ethnicity and mortality, especially neurology utilization. We also found that Hispanic veterans receive significantly less TBI clinic, neurology, rehabilitation and other types of utilization. The use of innovative system factors (decision aids, information tools, patient activation, and adherence support interventions) could be valuable in enhancing utilization of specific TBI related services, especially among ethnic minorities.

Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review

“…Two studies used statewide databases: Oregon Hospital Discharge Data Index (HDDI) and New York State Inpatient Databases Healthcare Cost and Utilization Project 16,17 . One study of veterans with TBI used data from Veterans Health Administration (VHA) Decision Support System (DSS) and Vital Status files 18 . Three other studies enrolled participants based on the records from local hospitals or trauma centers including Northwestern Memorial Hospital (NMH), Northwestern level I trauma center and Neurology/Neurosurgery Intensive Care Unit (NNICU) 19–21 .…”

“…Missios et al focused on the procedural volumes that patients received during hospitalization for TBI in their study 13 . In addition, seven of the 11 studies examined discharge destinations, rehabilitation use or outpatient follow-up visits to health care settings as outcomes 11,12,15,16,18–20 .…”

Geographic Disparities in Mortality Risk Within a Racially Diverse Sample of U.S. Veterans with Traumatic Brain Injury

“…These findings may be a result of differential utilization, as previous research suggests that Hispanic veterans were less likely to utilize TBI services, including specialty clinics, neurology, and rehabilitation services in the VA health care system. 12 , 14 Low service utilization could lead to condition exacerbation or failure to identify preventable medical conditions early and before becoming chronic.…”

“… 10 , 11 In addition, although Hispanic veterans are more likely than their non-Hispanic White peers to have greater TBI severity, they are less likely to utilize TBI services, including specialty clinics, neurology, and rehabilitation services in the VA health care system. 10 , 12 Ethnic and racial disparities in health care are particularly concerning in the VA health care system, which aims to be an equal access network of government-administered, comprehensive health care facilities that serves >9 million veterans, with ∼22% being individuals from racial or ethnic minority backgrounds. 13…”

Race/Ethnicity and Retention in Traumatic Brain Injury Outcomes Research: A Traumatic Brain Injury Model Systems National Database Study

“…9 Blacks and Hispanics with TBI have been shown to have poorer outcomes compared with whites in overall functioning, 10 functional independence, 11 independence in home activities, 12 employment outcomes, 13,14 and satisfaction with participation. 15 Minorities have also been shown to utilize rehabilitation services less than whites in both civilian 16 and military 17 samples. These findings emphasize the need for inclusion of minorities in longitudinal research and clinical trials targeting TBI, as their exclusion can yield a biased view of outcomes.…”