1. Disease Burden, Utilization and Costs of Care Among Women Using Veterans Health Administration HERC Cyber Seminar May 25, 2005 Presented by Ciaran Phibbs

2. 2 Co-authors Susan Frayne Wei Yu Lakshmi Ananth Samina Iqbal Ann Thrailkill Elizabeth Yano

3. 3 Background VA provides comprehensive health care services: Psychiatric and Substance abuse Only recently have healthcare cost data become available for the VA Health Care System.

4. 4 Background Services for women veterans becoming a higher priority as their numbers increase Very limited information on women veterans and their use of VA services

5. 5 Objectives 1)To build off of our previous work looking at chronic conditions in all veterans,looking for differences by gender. 2)Work on the methods for indentifying female patients in VA

6. 6 Background Previous work, Yu, W, Ravelo A, Wagner TH, Phibbs CS, Bhandari A, Chen S, Barnett PG. Prevalence and Costs of Chronic Conditions in the VA Health Care System. Medical Care Research and Review, 2003;60:146S-167S.

7. 7 Methods: Data and Sample Entire population of VA Health Care System users in FY 2002, profiled for common chronic diseases –4,444,577 persons –4,433,121 after deletions for missing data Supplemented with conditions important to women.

8. 8 Methods: Identification of Women VA Users 99.96 % of patients had consistent gender recorded across all health care encounters. 1,757 cases of discrepant gender. For 1,151 >=50% of records listed patient as female. Excluded other 606 patients

9. 9 Methods: Identification of Chronic Conditions Patients with 29 common chronic diseases identified by ICD-9 codes in 2 databases: 1.Inpatient: Main File of the Patient Treatment File database (PTF) 2.Outpatient: Event File of the National Patient Care Database (NPCD)

10. 10 Methods: Classification of Chronic Conditions ICD-9 classification methods of health conditions based on review of: –Kaiser Permanente study (Ray et al 2000) –Previous VA studies –Clinical Classifications Software (CCS) developed by the Agency for Healthcare Research and Quality (AHRQ). Any significant differences in disease classification were reviewed by physicians.

11. 11 Methods: Addition of Conditions Important to Women Gender-specific conditions from CCS Reviewed list of conditions from VA’s National Women’s Health Project. Reviewed by a panel of physicians Based on numbers of similarity, collapsed some conditions, especially CCS for tractability.

12. 12 Methods: Female-Specific Conditions Menopausal disorders Inflammatory female pelvic disorders Menstrual disorders Other female genital disorders Pregnancy Infertility Contraceptive management Benign female pelvic neoplasms Nonmalignant breast conditions Female pelvic malignancies Breast cancer

13. 13 Methods: Male-Specific Conditions Two conditions from the original list were identified as male-specific conditions –Prostatic hypertrophy –Prostate cancer

14. 14 Methods: Determination of Medical Care Cost (1) Annual costs include: –Inpatient care: Med/Surg and all other costs –Outpatient care –Outpatient prescription drugs –Does not include non-VA providers

15. 15 Methods: Determination of Medical Care Cost (2) All data from HERC person-level cost files –Inpatient and Outpatient care costs determined using HERC Average Cost Database –Outpatient prescription drug costs reported by the VA Decision Support System (DSS) National Data Extract

16. 16 Methods: Determination of Veteran’s Status All VA PTF and NPCD records indicate veteran status. –Check for agreement across records; found very high agreement –Created categorical variable to identify veteran’s vs. non-veteran’s

17. 17 VA Users, By Gender and Veteran’s Status MaleFemale Veteran3,940,148178,463 Non-Veteran129,470185,040

18. 18 Eligibility of Non-Veteran Female Users of VA Care, N=185,040 106,412 employees 25,283 VA sharing agreements 19,764 collaterals (eligible family members) 15,154 CHAMPVA 10,513 TriCare

19. 19 Age Distributions of Female and Male Veterans Who Used VA in FY 2002 WomenMen Age (%)N=178,463N=3,940,148 <4542.59.4 45-5425.818.0 55-6410.020.1 65-747.126.3 75+14.626.2

20. 20 Race/Ethnicity Distribution of Female and Male Veterans Who Used VA in FY 2002 WomenMen Race/Ethnicity (%) N=178,463N=3,940,148 White39.642.9 Black13.49.0 Hispanic1.93.4 Other0.60.5 Unknown44.644.2

21. 21 Marital Status of Female and Male Veterans Who Used VA in FY 2002 WomenMen Marital Status (%) N=178,463N=3,940,148 Married34.160.8 Divorced27.618.3 Widowed9.66.8

22. 22 VA Eligibility of Female and Male Veterans Who Used VA in FY 2002 WomenMen VA Eligibility (%)N=178,463N=3,940,148 Cat A, service connected 42.230.9 Cat A, non-service connected 36.240.0 Category C16.326.3

23. 23 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 Cardio-WomenMenAge-Adj vascularN=178,463N=3,940,148OR Hypertension28.648.90.65 Ischemic5.520.40.38 CHF1.64.50.59 Peri Vas Dis1.34.40.49

24. 24 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 WomenMenAge-Adj N=178,463N=3,940,148OR COPD4.410.00.65 Asthma6.22.52.35 Acid disorders 3.13.70.90 Hepatitis C1.32.10.32

25. 25 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 WomenMenAge-Adj N=178,463N=3,940,148OR Low back15.811.61.10 Arthritis16.617.81.08 Injury12.68.11.27 Osteoporosis5.50.813.64

26. 26 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 WomenMenAge-Adj N=178,463N=3,940,148OR Stroke1.02.20.68 MS0.90.32.51 Headache17.82.65.59 Dementia0.71.21.15

27. 27 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 WomenMenAge-Adj N=178,463N=3,940,148OR Depression22.811.51.69 PTSD6.75.10.88 Schizophrenia3.02.40.76 Bipolar4.41.71.62

28. 28 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 WomenMenAge-Adj N=178,463N=3,940,148OR Paranoid1.31.20.90 Personality2.40.71.93 Substance11.713.40.54 Other psych31.720.81.33

29. 29 Frequency and Age-Adjusted Odds Ratios By Gender, VA Users FY 2002 SummaryWomenMenAge-Adj N=178,463N=3,940,148OR Any medical65.677.90.81 Male14.5 Female31.6 Mental Health 38.029.91.01

30. 30 Summarization of Utilization and Costs Aggregated the chronic/clinical conditions into four groups –No medical or mental health conditions –Medical conditions only –Mental health conditions only –Both medical and mental health conditions

31. 31 Distributions of Women and Men Veterans By Health Conditions NoneMedicalMental Health Both Women43,56067,01017,74850,145 Men640,6272,119,981228,211951,329 Age Women43.856.042.550.4 Men59.567.252.760.9

32. 32 VA Utilization By Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Num OP Women5.113.715.531.9 Men4.212.716.627.4 Num IP Women1.210.942.533.50 Men2.581.374.674.62

33. 33 Inpatient VA Utilization By Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Med/Surg Women0.110.430.110.69 Men0.280.680.241.09 MH/SA Women0.050.001.260.99 Men0.110.011.740.86

34. 34 Total Annual VA Costs for Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Women1,4223,1593,6407,279 (8,534)(8,774)(10,450)(13,769) Men2,1283,7564,3917,557 (14,001)(11,715)(13,206)(15,647)

35. 35 Total Inpatient VA Costs for Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Women6491,0281,4512,570 Men1,4561,6222,2993,4369

36. 36 Total Outpatient VA Costs for Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Women6141,4161,5253,242 Men5031,3371,5232,808

37. 37 Total VA Pharmacy Costs for Women and Men Veterans, By Health Conditions NoneMedicalMental Health Both Women1587156631,468 Men1707975681,313

38. 38 Conclusions Women veterans have different disease profiles, even after adjusting for age Women have more mental health conditions, but not on an age-adjusted basis Women veterans use more outpatient, and less inpatient care than men veterans Use of care varies greatly by condition