BACKGROUND/RATIONALE:
With the change in modern warfare and military operations, the injuries sustained by today’s soldiers are different from past military engagements. Injuries that probably would have resulted in death in earlier combat engagements are today not as lethal due to advances in military protective gear worn by the troops. As a result of greater survival, however, the returning OEF/OIF veterans may have a greater need for rehabilitation due to residual deficits from traumatic injury, or polytrauma injury, than any other period of service veterans preceding them. Unfortunately, very little is known about access to rehabilitation services, the rehabilitation needs or patient outcomes of OEF/OIF veterans who sustained injuries while on active duty.

OBJECTIVE(S):
(1) To identify a cohort of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) combat veterans who accessed Veterans Health Administration (VHA) facilities for conditions and injuries sustained while on active duty, merge the identified cohort with VHA workload data sets to obtain socio-demographics, medical diagnoses, and utilization information on these individuals, and to identify a subgroup of veterans who are potential candidates for physical medicine and rehabilitation services; (2) To use Geographic Information System (GIS) tools to ascertain veterans’ access to differing levels of VHA rehabilitation and medical services offered to veterans with potential need for rehabilitation services; and (3) To investigate the health services utilization, especially the receipt of both inpatient and outpatient rehabilitation services, provided to these veterans for a one year follow-up period.

METHODS:
The design is a retrospective, observational, cross-sectional study of a subgroup of OEF/OIF veterans who accessed the VA health care system during FY-03 and FY-04 and who are identified, based on their ICD-9 codes, as potential candidates for rehabilitation. Major characteristics: The specific groups of interest in this study are veterans who have ICD-9 codes that are associated with traumatic brain dysfunction, traumatic spinal cord dysfunction, traumatic amputation, vision impairment, orthopedic disorders, and burns. Based on preliminary data, we expected to find between 8,000 and 10,000 individuals in these diagnostic categories. Only veterans who received services in VHA are included. Major variables and source(s) of data: VA facility characteristics (i.e., level of care), patient characteristics (predisposing, enabling and need), and travel distance/travel time to the VA facility are the major variables. All information was obtained from extant VA data sources. Main types of analysis: The analysis plan for this study is divided into two phases. The first phase employs GIS tools to map the location of returning war fighters in relation to where VHA rehabilitation services are available and identifies potential gaps in services (Objectives 1 and 2). The second phase uses a two-part model (logistic regression and poisson regression) to estimate (1) the receipt of any specialized rehabilitation services; (2) the volume of VHA rehabilitation service use (Objective 3).

FINDINGS/RESULTS:
We identified 7,842 OEF/OIF individuals with traumatic injury. Audiological impairment was the most common traumatic injury, with 63.5% of the cohort having a diagnostic code in this group; Visual Impairment was the second most common (27.9%) followed by: Orthopedic (5.2%), Traumatic Brain Dysfunction (4.2%), Burns (2.1%), Spinal Cord Injury (1.6%), and Amputation (1.3%). Four hundred twenty-seven (427) veterans, or 5.4%, in the cohort suffered polytraumatic injuries. The mean age was 35.6 years; 311 (4%) of those traumatically injured were 55 years of age and older. Approximately eight percent (7.9%) of the combined cohort were women. White race is the majority of those individuals identified with traumatic injury (65.1%); 16.5% were hispanic and 13.2% were African Americans. Median distance to Level I, Level II, and Level III facility was 411 miles, 121 miles, and 64 miles respectively. The median distance to the closest VA facility was 22 miles. Overall, the VHA Polytrauma System of Care provided reasonable rehabilitation access to 87.1% of inpatient and 88.3% of outpatient users of VHA services for the FY03 & FY04 cohorts. Impairment groups where 20% or more of patients were outside of reasonable drive time were: inpatient burns (21%), inpatient traumatic amputation (20%) and outpatient traumatic amputation (25%).

Four counties in Alabama (Marion, Lamar, Madison, and Mobile) and 1 county in each of the following states: Nevada (Clark), North Dakota (Ward), Texas (El Paso), Hawaii (Honolulu), Alaska (Anchorage), and Mississippi (Jackson) were identified as areas with potential rehabilitation access gaps. Clark County, Nevada and El Paso County, Texas had the highest number of patients outside of the drive time bands.

Of the 7,842 patients in our combined cohort, 1,569 (20%) received rehabilitation services either in the outpatient or the inpatient setting over a 12 month period. Variables in the model reaching statistical significance for odds of receiving rehabilitation versus not receiving rehabilitation are: being African American, distance to Level II facilities, and type of impairment. As compared to whites, African Americans have 23.5% higher odds of receiving rehabilitation services. For each mile a veterans is closer to a Level II polytrauma center, the odds of receiving rehabilitation services are increased by 1%. Impairment types that have the greatest odds of rehabilitation use are: Spinal Cord Dysfunction (OR: 17.119), Traumatic Amputation (OR: 15.305), Traumatic Brain Injury (OR: 6.669), and Orthopedic Injury (OR: 5.278).


IMPACT:
Rehabilitation services are especially important in the VA today given that OEF/OIF veterans are returning with service-connected traumatic brain dysfunction, traumatic spinal cord dysfunction, traumatic amputation, vision impairment, orthopedic disorders, burns and/or polytrauma injury. Despite this importance, access to specialized rehabilitation services in the VA has been shrinking. Given the value of these services and the dramatic reduction in the number of specialized rehabilitation units in the VA, it becomes critically important that the remaining VA rehabilitation resources are located where there is the greatest need for such services. If new resources are added for rehabilitation services, it is equally important to locate them where they will provide the largest impact in terms of filling service gaps and unmet need. Preliminary results from this study, in part, resulted in the recommendation by PM&RS Service to upgrade San Juan Medical Center to a Level II Polytrauma facility (pending). A Management Report denoting potential access gaps was submitted to the National Program Office for Physical Medicine and Rehabilitation.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Cowper-Ripley DC, Reker DM, Hayes J, Vogel B, Wu SS, Beyth RJ, Sigford BJ, Litt ER, Wang X, Cowper Ripley D. Geographic Access to VHA Rehabilitation Services for Traumatically Injured Veterans. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2009 Oct 1; 26(10):28-39. [view]
2. Culpepper WJ, Cowper-Ripley D, Litt ER, McDowell TY, Hoffman PM. Using geographic information system tools to improve access to MS specialty care in Veterans Health Administration. Journal of rehabilitation research and development. 2010 Aug 1; 47(6):583-91. [view]

Conference Presentations

1. Cowper Ripley DC, Reker DM, Vogel WB, Hayes JM, Beyth RJ, Litt E, Dewald L, Wang X, Wu SS. Geographic Access to VHA Rehabilitation Services by OEF/OIF Veterans. Paper presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD. [view]
2. Cowper Ripley DC. Using GIS for Epidemiological Studies. Paper presented at: VA Office of Rural Health / Maine Medical Center Conference on Health Care for the Rural Maine Veteran; 2011 Apr 26; Portland, ME. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury, Military and Environmental Exposures
DRE: none
Keywords: Access, Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none