ML Maciejewski, Seattle HSR&D, VA Puget Sound Health Care System; D Hickam, Seattle HSR&D, VA Puget Sound Health Care System; S Joos, Seattle HSR&D, VA Puget Sound Health Care System; C Dougherty, VA Puget Sound Health Care System; S Hunt, VA Puget Sound Health Care System; R Richardson, VA Puget Sound Health Care System

To compare the utilization and costs of veterans seen in an established Persian Gulf War clinic to that of veterans receiving conventional care in other VA medical center (VAMC) clinics at the VA Puget Sound Health Care System.

Methods: 603 veterans who had served in the Persian Gulf War conflict were sampled for an evaluation of an established Gulf War clinic that provided coordinated care for physical and mental health issues. The outpatient and inpatient utilization and costs for 182 of 603 veterans who were seen in this clinic and 481 Gulf War veterans who were seen in other outpatient clinics at the Seattle VAMC were tracked for fiscal years 1998, 1999, and the first two quarters of fiscal year 2000 from DSS. Utilization and costs were grouped into seven categories: primary care, mental health, non-mental health specialty, ancillary and other, total outpatient, total inpatient, and overall costs. Multivariate regressions were run to control for the confounding of important veteran characteristics. Utilization analyses were estimated using negative binomial regressions to account for overdispersion in the count data, with a log link function. Health care costs were estimated using least squares regression. Both sets of equations controlled for demographic characteristics, a health status proxy measure (Diagnostic Cost Group (DCG)), and a dummy variable indicating whether or not the veteran had been seen in the Gulf War clinic. All regressions included fixed effects for time and a variance correction for repeated measures.

Results: There were no significant demographic differences between Gulf War clinic and non-Gulf War clinic patients. In regressions that controlled for demographics and DCGs, veterans seen in the Gulf War clinic had significantly higher utilization and costs per year for primary care, mental health, specialty, and total outpatient than veterans seen in other clinics. Gulf War clinic patients had two more primary care visits and four more mental health visits per year than non-Gulf War clinic patients. Primary care and mental health care costs per year for Gulf War clinic patients were $300 and $650 higher, respectively. Specialty care costs were nearly $300 higher for Gulf War clinic patients. Overall inpatient and outpatient costs per year were nearly $2100 greater for veterans seen in the Persian Gulf War clinic, primarily due to greater outpatient costs.

Conclusions: The Seattle Gulf War Veterans’ Clinic clinical philosophy is predicated on the principle that aggressive interventions should encompass a comprehensive, integrated approach as part of the treatment strategy. Veterans were encouraged to enroll in exercise/cognitive behavior therapy treatment programs, group therapy, smoking cessation programs, and substance abuse treatment programs. These efforts also included additional primary care visits for education, health assessments associated with the intervention programs and ongoing monitoring of health concerns during participation in the programs. Clinic users also represent a sub-group of Gulf War veterans with more complex and more "serious" health concerns, particularly in mental health. If health outcomes and patient satisfaction improve and medical and disability-related costs decrease in the long term, higher expenditures for Gulf War clinic patients, which may be incurred in part by identifying unmet mental and physical health needs, may be justified.

Impact: This study indicates the possible resource use associated with the establishment of a clinic that integrates physical and mental health services for Gulf War veterans. The aggressive treatment of Gulf War-related symptoms may be more costly to treat in short-term, specialized clinics when fully operative.