3018 — Race/Ethnicity, Utilization, and Mortality Among Veterans with TBI
Dismuke CE (Center for Disease Prevention and Health Interventions for Diverse Populations), Echols C
(Center for Disease Prevention and Health Interventions for Diverse Populations), Gebregziabher M
(Center for Disease Prevention and Health Interventions for Diverse Populations), Egede LE
(Center for Disease Prevention and Health Interventions for Diverse Populations)
Racial/ethnic disparities in mortality among Veterans with Traumatic Brain Injury (TBI) have been documented. However, there is a paucity of information regarding the role Veterans Administration (VA) services utilization may have in these disparities. This study examined the association between race/ethnicity, VA service utilization, and all-cause mortality among veterans with TBI.
A cohort study of 14,708 Veterans with ICD-9 codes for TBI was created by merging multiple national datasets from the VA. The cohort was followed for death from January 1, 2006 to either date of death or December 31, 2009 while utilization and co-morbidities were for the year 2006. Unadjusted means of VA TBI clinic, imaging, neurology, rehabilitation, and primary care/other specialty care visits were estimated. Available covariates included demographics (i.e., age, rural/urban residence, insurance use) and ICD-9 coded comorbidities. In order to control for unobserved Veteran characteristics affecting utilization and mortality, predicted values of utilization were estimated using Poisson regression adjusting for covariates. A Cox proportional hazards regression model was used to calculate hazard ratio (HR) of death across all racial/ethnic groups, after sequentially controlling for demographics, comorbidities, observed utilization, and predicted utilization in a fully adjusted model. All statistical tests used a p < = 0.05 level of significance and were performed using SAS statistical software.
Unadjusted mortality was significantly higher for Hispanics relative to non-Hispanic Whites (NHW).(HR 2.33; 95% CI 1.49: 3.64). After controlling for unobserved Veteran characteristics in a fully adjusted model, Hispanic ethnicity (HR 1.75; 95% CI 1.03;2.98) and non-Hispanic Black NHB (HR 1.47; 95% CI 1.050:2.060) were associated with higher mortality. Increasing age, Medicare coverage, and lung disease were also associated with higher mortality. Predicted rehabilitation visits (HR 0.12; 95% CI 0.02:0.63) were associated with lower mortality in all Veterans as was a diagnosis of hypertension (HR: 0.91; 95% CI 0.023:0.638).
Minorities received fewer visits in all categories of VA clinic services. NHB and Hispanic Veterans have higher mortality rates after adjusting for utilization. Rehabilitation services appear to reduce mortality among Veterans with TBI.
Rehabilitation services should be increased for all Veterans with TBI.