BACKGROUND/RATIONALE:
Specialized rehabilitation services have been shown to yield important benefits to patients with spinal cord injury (SCI), traumatic brain injury (TBI), and amputation. Such services are especially important in the VHA because veterans have a high incidence and prevalence of service-connected SCI, TBI, and amputation. Consequently, VHA patients with these conditions have been designated as Special Emphasis Populations, and the VHA is charged by law to provide reasonable access to services that meet the specialized treatment and rehabilitative needs of these veterans.
Despite this importance, access to specialized rehabilitation services in the VHA has been shrinking. In the past 10-15 years, the number of VHA medical centers with formal inpatient rehabilitation bed sections has dropped from 82 to 45, a decrease of 45 percent. Given the importance of these services and the dramatic reduction in the number of specialized rehabilitation units in the VHA, it becomes critically important that the remaining VHA rehabilitation resources are located where there is the greatest need for such services. The purpose of this research was to identify geographic regions where the need for VHA rehabilitation services among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with SCI, TBI, and amputations is greatest, and where there is the highest likelihood of reduced access and unmet need for such services in this veteran population.

OBJECTIVE(S):
The objective of this proposed research is to improve access to rehabilitation services for OEF/OIF veterans with SCI, TBI, and amputations. We have achieved this objective by identifying those geographic areas and their injured OEF/OIF veteran cohorts which have the greatest potential demand for VHA rehabilitation services, where potential demand is defined as the additional demand for VHA rehabilitation services that would occur if VHA rehabilitation services were more available and accessible to these veterans. We have answered the following two questions in the course of this research project: (1) How would VHA enrollment and rehabilitation use among injured OEF/OIF veterans likely change if VHA expanded the locations and supply of VHA rehabilitation services?, and (2) Which geographical areas and their injured OEF/OIF veteran cohorts are presently at greatest risk of lack of access to any rehabilitation services, including both VA and community services?

METHODS:
We used both statistical models of VA rehabilitation utilization and Geographic Information System (GIS) tools to develop predictions of how VA rehabilitation use would change among OEF/OIF veterans if VA rehabilitation units were opened at VAMCs that presently lack such units. In accomplishing this work, we have worked closely with VHA Physical Medicine & Rehabilitation Service (PM&RS) to identify potential expansions of rehabilitation services that are both feasible and sensible from clinical and administrative viewpoints.
We combined VA data from the VA Functional Status Outcomes Database (FSOD), VA enrollment files, medical SAS datasets, and OEF/OIF roster with non-VA data from the 2007 American Hospital Association annual survey and the Area Resource File. These non-VA data sources allowed us to account for the impact of community hospital (AHA) and county-level rehabilitation resources (ARF) on VHA rehabilitation use. We also used VA geographical utilization patterns along with GIS tools to develop 153 VAMC-specific catchment areas for OEF/OIF veterans that span the entire continental U.S. These catchment areas formed the units of analysis for our statistical models.

FINDINGS/RESULTS:
Our key results focus on the answers to our research questions. To examine where the greatest increase in OEF/OIF rehabilitation use was likely to occur if new rehab units were opened (research question 1), we estimated the increase in OEF/OIF rehabilitation use that would result from the reduced travel time associated with the opening of a new rehab unit. The ten VA catchment areas that show the largest percentage increases in OEF/OIF rehab use are (% increase, # new patients) (1) Boise (88%, 43 pts.), (2) Salt Lake City (84%, 43 pts.), (3) Fort Harrison (82%, 51 pts.), (4) Biloxi/Gulfport (67%, 27 pts.), (5) Fort Meade (65%, 35 pts.), (6) Sheridan (62%, 48 pts.), (7) Jackson (60%, 19 pts.), (8) Tuscaloosa (58%, 17 pts.), (9) Amarillo (58%, 30 pts.), and (10) Gulf Coast (58%, 44 pts.).
To examine which catchment areas were at the greatest risk of unmet need, we predicted the maximum access demand for OEF/OIF rehabilitation care by substituting the travel time for the nearest community hospital that offered outpatient rehabilitation services as indicated by the 2007 AHA annual survey. The ten VA catchment areas that show the largest percentage increases in OEF/OIF rehab use under maximum access are (% increase, # new patients) (1) Fort Harrison (118%, 73 pts.), (2) Salt Lake City (100%, 52 pts.), (3) Boise (97%, 47 pts.), (4) Sheridan (89%, 70 pts.), (5) Fort Meade (89%, 47 patients), (6) Amarillo (82%, 61 pts.), (7) Gulf Coast (74%, 38pts.), (8) Biloxi/Gulfport (74%, 29 pts.), (9) Jackson (72%, 22 pts.), and (10) Nebraska-Western Iowa (70%, 31 pts.).
To supplement these statistical results, we also conducted a GIS-based "gap" analysis focused on existing utilization patterns of OEF/OIF veterans. These results showed considerable overlap (roughly 40%) with the statistical analyses, suggesting that existing use patterns and use patterns under different "what-if" scenarios yield similar answers regarding catchment area priorities.

IMPACT:
The results of this research have identified key catchment areas with the greatest potential demand for specialized VA rehabilitation resources and have confirmed that numerous such areas have potential demand that exceeds minimum optimal scale for rehabilitation units. Consequently, these results establish a strong case for expanded rehabilitation capacity for OEF/OIF veterans with SCI, TBI, and amputations.

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External Links for this Project

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PUBLICATIONS:

Conference Presentations

1. Vogel WB. HSR&D Scientific Merit Review Board (SMRB): The Process. Presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]
2. Vogel WB, Kairalla J, Wang X, Litt ER, Castro JG, Wilson LK, Cowper Ripley DC, Reker DM. Predicting Potential Demand for OEF/OIF Rehabilitation Services in the VHA. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD. [view]
3. Litt ER, Vogel WB, Kairalla J, Cowper Ripley DC, Wilson LK, Castro JG, Wang X. Using GIS Tools in Prioritizing Rehabilitation Service Sites for OEF/OIF Veterans. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; Washington, DC. [view]
4. Vogel WB, Kairalla J, Cowper Ripley DC, Litt ER. VHA Enrollment Rates across the Rural-Urban Continuum. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]

DRA: Health Systems, Acute and Combat-Related Injury
DRE: Treatment - Observational
Keywords: Access, Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none