Ethnicity/race and service-connected disability disparities in civilian traumatic brain injury mechanism of injury and VHA health services costs in military veterans: Evidence from a Level 1 Trauma Center and VA Medical Center

Abstract

Introduction

The objective of this study was to examine the association of military veteran socio-demographics and service-connected disability with civilian mechanism of traumatic brain injury and long-term Veterans Health Administration (VHA) costs.

Methods

We conducted a 17-year retrospective longitudinal cohort study of veterans with a civilian-related traumatic brain injury from a Level 1 Trauma Center between 1999 and 2013, with VHA follow-up through 2016. We merged trauma center VHA data, and used logit to model mechanism of injury, and generalized linear model to model VHA costs.

Results

African American race or Hispanic ethnicity veterans had a higher unadjusted rate of civilian assault/gun as mechanism of injury (15.38%) relative to non-Hispanic White (7.19%). African American race or Hispanic veterans who were discharged from the trauma center with traumatic brain injury and followed in VHA had more than twice the odds of assault/gun (OR 2.47; 95% CI 1.16:5.26), after adjusting for sex, age, and military service-connected disability. Veterans with service-connected disability ≥50% had more than twice the odds of assault/gun (OR 2.48; 95% CI 0.97:6.31). Assault/gun was associated with significantly higher annual VHA costs post-discharge ($16,807; 95% CI 672:32,941) among non-Hispanic White veterans. Military service-connected disability ≥50% was associated with higher VHA costs among both non-Hispanic White ($44,987; 95% CI $17,159:$72,816) and African American race or Hispanic ($37,901; 95% CI $4,543:$71,258) veterans.

Conclusions

We found that African American race or Hispanic veterans had higher adjusted likelihood of assault/gun mechanism of traumatic brain injury, and non-Hispanic White veterans had higher adjusted annual VHA resource costs associated with assault/gun, post trauma center discharge. Veterans with higher than 50% service-connected disability had higher likelihood of assault/gun and higher adjusted annual VHA resource costs. Assault/gun prevention efforts may be indicated within the VHA, especially in minority and service-connected disability veterans. More data from Level 1 Trauma Centers are needed to assess the generalizability of these findings.

Keywords

Traumatic brain injury veterans injury mechanism costs disparities

Get full access to this article

View all access options for this article.

References

Aarabi

Mossop

Aarabi

Surgical management of civilian gunshot wounds to the head. In: Grafman

Salazar

(eds). Handbook of Clinical Neurology 2015; Vol. 127 Waltham, MA: Elsevier, 2015, pp. 181–193.

American Association of Neurological Surgeons. Gunshot wound head trauma, https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Gunshot-Wound-Head-Trauma (2018, accessed 12 October 2018).

Kazim

Shamim

Tahir

, et al. Management of penetrating brain injury. J Emerg Trauma Shock 2011; 4: 395–402.

Centers for Disease Control and Prevention. Surveillance report of traumatic brain injury-related emergency department visits, hospitalizations, and deaths – United States, 2014. , Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2019.

Bertisch

Krellman

Bergquist

, et al. Characteristics of firearm brain injury survivors in the traumatic brain injury model systems (TBIMS) national database: a comparison of assault and self-inflicted injury survivors. Arch Phys Med Rehabil 2017; 98: 2288–2294.

Military Health System and the Defense Health Agency Traumatic Brain Injury (TBI) DoD Standard Surveillance Case Definition for TBI Adapted for AFHSB use. AFHSB Surveillance Case Definitions FINAL April 2016. Military Health System and the Defense Health Agency, https://health.mil/Military-Health-Topics/Health-Readiness/Armed-Forces-Health-Surveillance-Branch/Epidemiology-and-Analysis/Surveillance-Case-Definitions (2016, accessed 12 October 2018).

Gardner

Byers

Barnes

, et al. Mild TBI and risk of Parkinson disease: a chronic effects of neurotrauma consortium study. Neurology 2018; 90: e1771–e1779.

Demetriades

Kuncir

Murray

, et al. Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries. J Am Coll Surg 2004; 199: 216–222.

Chien

Hwang

Lin

. Injury severity measures for predicting return-to-work after a traumatic brain injury. Accid Anal Prev 2017; 98: 101–107.

10.

Health Economics Resource Center. Average cost, https://www.herc.research.va.gov/include/page.asp?id=average-cost (2019, accessed 13 June 2019).

11.

US Department of Labor. Consumer Price Index (CPI) inflation calculator, https://data.bls.gov/cgi-bin/cpicalc.pl (2019, accessed 13 June 2019).

12.

Polgreen

Brooks

. Estimating incremental costs with skew: a cautionary note. Appl Health Econ Health Policy 2012; 10: 319–329.

13.

Faul

Wald

, et al. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths, 2002–2006, Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2010.

14.

Langlois

Rutland-Brown

Wald

. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006; 21: 375–378.

15.

Harrison-Felix

Zafonte

Mann

, et al. Brain injury as a result of violence: preliminary findings from the traumatic brain injury model systems. Arch Phys Med Rehabil 1998; 79: 730–737.

16.

Hanks

Wood

Millis

, et al. Violent traumatic brain injury: occurrence, patient characteristics, and risk factors from the traumatic brain injury model systems project. Arch Phys Med Rehabil 2003; 84: 249–254.

17.

Asemota

George

Cumpsty-Fowler

, et al. Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. J Neurotrauma 2013; 30: 2057–2065.

18.

Dismuke

Gebregziabher

Egede

. Racial/ethnic disparities in VA services utilization as a partial pathway to mortality differentials among veterans diagnosed with TBI. Glob Health Sci 2016; 8: 260–260.

19.

da Silva Cardoso

Romero

Chan

, et al.

Disparities in vocational rehabilitation services and outcomes for Hispanic clients with traumatic brain injury: do they exist?

J Head Trauma Rehabil 2007; 22: 85–94.

20.

Bowman

Martin

Sharar

, et al. Racial disparities in outcomes of persons with moderate to severe traumatic brain injury. Med Care 2007; 45: 686–690.

21.

Nirula

Gentilello

. Inequity of rehabilitation services after traumatic injury. J Trauma Acute Care Surg 2009; 66: 255–259.

22.

Meagher

Beadles

Doorey

, et al. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. J Neurosurg 2015; 122: 595–601.

23.

Cuthbert

Corrigan

Harrison-Felix

, et al. Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2011; 92: 721–730.

24.

Englum

Villegas

Bolorunduro

, et al. Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma. J Am Coll Surg 2011; 213: 699–708.

25.

Saha

Freeman

Toure

, et al. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med 2008; 23: 654–671.

26.

Tsai

Desai

Cheng

, et al. The effects of race and other socioeconomic factors on health service use among American military veterans. Psychiatr Q 2014; 85: 35–47.

27.

Logan

Fowler

Patel

, et al. Suicide among military personnel and veterans aged 18–35 years by county – 16 states. Am J Prev Med 2016; 51: S197–S208.

28.

Brenner

Carlson

Harrison-Felix

, et al. Self-inflicted traumatic brain injury: characteristics and outcomes. Brain Inj 2009; 23: 991–998.

29.

Fabrizio

Keltner

. Traumatic brain injury in Operation Enduring Freedom/Operation Iraqi Freedom: a primer. Nurs Clin 2010; 45: 569–580.

30.

Menon

Schwab

Wright

, et al. Demographics and clinical assessment working group of the international and interagency initiative toward common data elements for research on traumatic brain injury and psychological health. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil 2010; 91: 1637–1640.

31.

Center for Military Health Policy Research. Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery, https://www.rand.org/content/dam/rand/pubs/monographs/2008/RAND_MG720.pdf (2008, accessed 13 June 2019).

32.

Kysar-Moon

Mustillo

. Race/ethnicity and traumatic brain injury: are there disparities in positive screenings and diagnoses among service members returning from Afghanistan and Iraq? Armed Forces Soc 2019; 45: 155–176.

33.

Dismuke

Gebregziabher

Yeager

, et al. Racial/ethnic differences in combat- and non–combat-associated traumatic brain injury severity in the Veterans Health Administration: 2004–2010. Am J Public Health 2015; 105: 1696–1702.

34.

Renson

Shubert

Bjurlin

. Lack of health insurance associated with lower probability of head computed tomography among United States trauma brain injury patients. Med Care 2018; 12: 1035–1041.

35.

Liu

C-F

Batten

Wong

, et al. Fee-for-service Medicare-enrolled elderly veterans are increasingly voting with their feet to use more VA and less Medicare, 2003–2014. Health Serv Res 2018; 53: 5141–5158.