Healthcare utilization patterns and associated costs for Gulf War I Era Veterans

 描述(由申请人提供)： 背景：在1990-1991年海湾战争期间，约有70万名军人被部署到海湾地区。另有400万人部署在其他地方或驻扎在国内。在这个队列中，增加的症状，包括一种独特的慢性多症状疾病模式，已经被很好地记录下来。在第一次海湾战争时期的退伍军人中，有证据表明功能状态更差，症状体验增加，以及随后医疗保健利用率的潜在增加(程度较少为人所知)。这些工作的大部分是在冲突后的头十年内完成的。在这个时点，这群退伍军人年龄大约在40-60岁，可能会经历与老龄化相关的额外健康问题，如癌症和心血管疾病风险增加。尽管有较早的研究，但在当前的诊断、医疗保健利用模式、成本和对这个时代退伍军人护理的满意度方面，知识仍然存在重大差距。目标：为了改善海湾战争时期退伍军人得到的护理，本提案的目标是全面了解海湾战争时期退伍军人的书面诊断、医疗保健利用模式和成本，以及患者报告的传统和非传统医疗保健利用的决定因素、相关医疗保健成本、护理目标和满意度。为了实现这些目标，我们将追求三个具体目标：(1)描述90,000名第一次海湾战争时期退伍军人的分层随机样本中VHA使用者的人口统计和临床特征；(2)描述我们样本中退伍军人的医疗保健利用模式和直接护理成本，包括总体上和预先指定的诊断组，包括慢性多系统疾病、心血管疾病、精神健康障碍、癌症、神经退行性疾病和复杂的慢性疾病；以及(3)探索退伍军人关于选择医疗保健提供者和利用的决策视角，以及他们的经验、护理目标和对所接受护理的满意度。在所有目标中，我们将根据包括海湾在内的特点来探索差异 战争部署、性别、年龄和其他社会人口学和临床特征。方法：我们将使用海湾战争时期队列和生物库(GWECB)项目现有潜在参与者池中现有的海湾战争时期退伍军人的分层随机样本。GWECB招募样本从国防人力数据中心维护的名册中获得，按海湾战争部署状态、服务组成部分和分支机构、级别、种族和性别进行分层。对于本样本中使用过退伍军人医疗保健的退伍军人(约51,000人)，我们将从以下管理和临床数据来源获取有关患者特征、有记录的诊断以及退伍军人医疗保健利用和成本的数据：医疗SAS住院和门诊患者档案、决策支持系统成本摘要和HERC平均成本数据集。使用这些数据，我们将描述退伍军人的人口素质和最常见的诊断和诊断群(目标1)，并对退伍军人的医疗保健利用和相关成本进行单变量和多变量分析(目标2)。在目标3中，我们将调查一个子样本，以评估自我报告的非传统形式的护理利用情况、对退伍军人和非退伍军人保健提供者的依赖、功能健康状况、护理目标和对护理的满意度。将与居住在达勒姆退伍军人医疗中心集水区的一部分调查受访者进行焦点小组讨论，以探讨他们对使用退伍军人医疗保健来源和非退伍军人医疗来源的决策观点。目前的提案是一个前所未有的机会，可以确定第一次海湾战争时期退伍军人未得到满足的需求，并制定新的创新战略，以改善他们的医疗保健和健康结果。

 DESCRIPTION (provided by applicant): Background: During the 1990-1991 Gulf War, approximately 700,000 service members were deployed to the Gulf region. An additional 4 million were deployed elsewhere or were domestically stationed. Increased symptomatology, including a unique pattern of chronic multi-symptom illness, among this cohort has been well documented. Among the Gulf War I era Veteran population there is evidence of worse functional status, increased experience of symptoms, and, to a lesser-known extent, subsequent potential increases in healthcare utilization. Much of this work was completed in the first ten years after the conflict. At this poit, this Veteran population is approximately age 40-60 years and likely experiencing additional health issues associated with aging, such as cancer and elevated cardiovascular disease risk. Despite the earlier research, significant gaps in knowledge remain regarding the current diagnoses, healthcare utilization patterns, costs, and satisfaction with care of Veterans of this era. Objectives: In order to improve the care Gulf War era Veterans receive, the objectives of this proposal are to establish a comprehensive understanding of Gulf War I era Veterans' documented diagnoses, healthcare utilization patterns and costs, and patient-reported determinants of traditional and non-traditional healthcare utilization, associated healthcare costs, goals of care, and satisfaction. To accomplish these objectives we will pursue three specific aims: (1) describe the demographic and clinical characteristics of VHA users within a stratified random sample of 90,000 Gulf War I era Veterans; (2) describe healthcare utilization patterns and direct care costs incurred by Veterans within our sample, both overall and for pre-specified diagnostic clusters, including chronic multi-system illness, cardiovascular conditions, mental health disorders, cancers, neurodegenerative conditions, and complex chronic disease; and (3) explore Veterans' decision-making perspectives regarding choice of healthcare providers and utilization, and their experiences, goals of care, and satisfaction with the care the have received. In all aims, we will explore differences according to characteristics including Gulf War deployment, sex, age, and other sociodemographic and clinical attributes. Methods: We will use an existing stratified random sample of Gulf War I era Veterans from an existing pool of potential enrollees in the Gulf War Era Cohort and Biorepository (GWECB) project. The GWECB recruitment sample, obtained from the rosters maintained by the Defense Manpower Data Center, is stratified by Gulf War deployment status, service component and branch, grade, race, and sex. For the Veterans in this sample who have ever used VA healthcare (approximately 51,000), we will obtain data about patient characteristics, documented diagnoses, and VA healthcare utilization and costs from the following administrative and clinical data sources: Medical SAS Inpatient and Outpatient files, Decision Support System cost extracts, and HERC average cost datasets. Using these data, we will characterize Veterans' demographic qualities and most common diagnoses and diagnostic clusters (Aim 1) and conduct univariate and multivariate analyses of Veterans' healthcare utilization and associated costs (Aim 2). In Aim 3, we will survey a subsample to assess self-reported utilization of non-traditional forms of care, reliance on VA and non-VA healthcare providers, functional health status, goals of care, and satisfaction with care. Focus groups will be conducted with a subset of survey respondents living in the Durham VA Medical Center catchment area to explore their decision- making perspectives regarding use of VA and non-VA sources of healthcare. The current proposal represents an unprecedented opportunity to identify the unmet needs of Gulf War I era Veterans and to develop new and innovative strategies to improve their healthcare and health outcomes.