1035 — Complex Comorbidity Clusters: Beyond the Polytrauma Clinical Triad
Pugh MJ, Noel PH, and Finley EP, VERDICT REAP; Amuan ME, CHQOER; Copeland LA, Central Texas Veterans Healthcare System; Pugh JA, VERDICT REAP;
Studies that describe physical or mental conditions among Veterans from Afghanistan and Iraq (OEF/OIF/OND) have focused primarily on the Polytrauma Clinical Triad: Traumatic Brain Injury (TBI), Post-traumatic Stress Disorder (PTSD), and chronic pain. The purpose of this study was to identify clusters of deployment-related, and chronic conditions in an OEF/OIF/OND cohort.
We used VA inpatient, outpatient, and pharmacy data to identify OEF/OIF/OND Veterans receiving VA care FY08-09, and identify conditions associated with TBI, blast injury, chronic pain, and chronic diseases using previously validated algorithms. We developed hierarchical clusters based on presence or absence of specific conditions. Clusters were examined for clinical relevance and labeled according to the proportion of individuals with the most distinguishing comorbidities. We then validated these clusters by examining medications prescribed and healthcare utilization in FY10.
A six-cluster solution emerged in the cohort of 191,806 OEF/OIF/OND Veterans: 1) Polytrauma Clinical Triad (100% PTSD, 100% pain, a high proportion TBI; N = 21,400; 2) 100% PTSD, 0% Depression, a high proportion TBI (N = 31,784); 3) 100% PTSD and Depression (N = 14,852); 4) 100% low back pain, 0% PTSD (N = 24,282); 5) 100% Depression, 0% PTSD (N = 15,245); 6) Relatively Healthy (N = 84,243). Medication use and healthcare utilization emerged as predicted for each cluster. For instance, antidepressant prescriptions were more common in clusters 1, 3, and 5 (68%; 78%; 62% respectively) vs. 10% in cluster 6 (p <.001). Similarly, individuals in clusters characterized by TBI were more likely to receive care in relevant clinics (e.g. neurology). Individuals in clusters characterized by PTSD and depression (1, 3, 5) were also more likely to have diagnoses of hypertension, osteoarthritis, obesity, and cardiac conditions, and to be treated with statins, antihypertensives, and hypoglycemic agents (all p <.001).
Although several clusters were defined by combinations of TBI, PTSD, and pain, the vast majority of OEF/OIF/OND Veterans did not exhibit the polytrauma clinical triad. Chronic diseases were also related to cluster membership. Nearly half of those who received care in FY08-09 were relatively healthy.
A systematic identification of common clusters of comorbidities may allow research/clinician partnerships to better predict individuals with greatest resource needs and risk for adverse events such as suicidality, and to determine more innovative and efficient ways to organize care delivery.