1.  More than 2 million men and women have been deployed to Afghanistan and Iraq for Operations Enduring Freedom/Iraqi Freedom (OEF/OIF).  ~21% of men and 11% of women VA patients have screened positive for traumatic brain injury (TBI), termed the “signature injury” of OEF/OIF.  These patients are referred for a comprehensive TBI evaluation (CTE) conducted by a VA clinician who uses a defined protocol to assist in making a clinical judgment about whether a TBI occurred (i.e., Positive TBI, Negative TBI, or Uncertain) and in developing a treatment plan.  The utilization of health care post-CTE may vary as a function of TBI diagnostic status, psychiatric comorbidities (e.g., PTSD) and demographic characteristics (e.g., age) Gender Differences in Veterans Affairs Outpatient Health Care Utilization Among OEF/OIF Veterans Following a Comprehensive Evaluation for Traumatic Brain Injury Maxine Krengel, PhD 1-2 ; Ann M. Hendricks, PhD 1,2,4 ; John Gardner, PhD 1,4 ; Errol Baker, PhD 1-3 ; Katherine M. Iverson, PhD 1-2,5 ; Terri Pogoda, PhD 1-3 ; Mark Meterko, PhD 1-3 ; Kelly L. Stolzmann, MS 1-3 1 VA Boston Healthcare System, Boston, MA; 2 Boston University, Boston, MA; 3 Center for Organization, Leadership and Management Research; ; 4 Health Care Financing & Economics; 5 Women’s Health Sciences Division, National Center for PTSD This material is based upon work supported by VA HSR&D Grant: SDR 08-405 INTRODUCTION  Centralized administrative records for all VA screenings and TBI evaluations from October 1, 2007 through June 30, 2009 were merged with Department of Defense records for service information ( N = 36,401).  Analysis included only those who did not report any pre- or post- deployment related TBI (n = 21,814).  During the study period, recorded TBI evaluation outcomes were: positive (+), negative (-) or uncertain (U).  VA utilization for 12 months post-evaluation date, psychiatric diagnoses, and demographic variables (e.g., gender, age, marital status) were compiled.  Clinic visits were categorized as related to TBI (polytrauma, TBI and physical therapy [PT]), mental health (psychiatry, psychology, PTSD, substance use disorder and counseling clinics), and medical clinics (primary care, cardiology, etc.).  Descriptive analyses compared frequencies or means and SD for demographic variables stratified by gender and TBI diagnostic status. Mean numbers of VA clinic visits were compared using t-tests. METHODS OBJECTIVES 1.We sought to determine differences in VA outpatient health care utilization in OEF/OIF Veterans by gender relative to TBI diagnosis and hypothesized that women would utilize more primary care and mental health care than their male counterparts, and this would be especially true for patients evaluated as having a TBI. 2.We also explored gender differences in VA healthcare utilization by demographic characteristics. RESULTS Gender Differences in Patient Characteristics  Compared to men, women with a CTE were more likely to be: An officer (4.8% vs. 3.5%) Single or never married (68.4% vs. 50.7%) In the Air Force or Navy (15.5% vs. 8.3%) Educated beyond high school (22.8% vs. 13.4%) In the military less time (only 18.2% had 8+years of service vs. 26.6%) Table 2. Demographic Characteristics of Evaluated VA Patients, by Gender Differences Within Gender Continued: For women, This pattern of increasing utilization exists for “Total clinic visits” Utilization of polytrauma-related care, PT, and TBI general clinics was significantly greater for those deemed TBI (+) than TBI (-). Those designated TBI (U) had significantly more visits than either TBI (-) or TBI (+) for PTSD and Other counseling. Differences Between Genders: Women evaluated TBI (+) or TBI (-) received significantly more VA outpatient care than men with those evaluation outcomes. Differences were accounted for by significantly more acute medical clinic visits, which were higher within the TBI (U) group as well. Women received PT more frequently than men when they were diagnosed as TBI (-). For mental health clinics, men had more utilization when deemed to be TBI (+) in clinics for substance abuse and other counseling. CharacteristicsMale N=34,028 Female N=2,078 Mean Age in 2008 (SD) 31.8 (9.0) 32.3 (8.8) Officer (%)3.54.8 Marital Status (%) Married Divorced/widowed Never Married 49.3 15.3 35.4 31.7 25.7 42.7 Education (%) High School or less More than HS Unknown 70.3 13.4 16.3 60.2 22.8 17.0 Service and Component (%) Army/Marines Regular Reserve Guard AF/Navy – Any component 39.2 28.9 22.1 8.3 35.3 26.7 20.8 15.5 Years of military service 0-3 4-7 8-26 27+ Not separated 39.4 33.7 21.1 5.5 0.3 45.3 35.6 13.9 4.3 0.9 In general, both women and men have considerable utilization of VA care 12 months after completion of their CTE, regardless of outcome of CTE. Women appear to be utilizing VA at rates greater than what was shown in previous research. They appeared to most often use acute medical care, use care if they were less well-educated and if they were older. In addition, women used more care if they were deemed to be TBI (+) or TBI (U) relative to TBI (-). Although the “uncertain” judgment was removed from the screening process, these results showed that men and women with an uncertain diagnosis had more clinic stops than those with a negative diagnosis. Given the differences between men and women in these analyses, impact of gender requires additional analyses to determine the marginal impact of demographics when other covariates are controlled. Table 1. Mean Number of Post-CTE Outpatient Clinic Stops Per Patient: Selected Categories of Clinic Stops by CTE TBI Finding and Gender Male a Female b TBI (+) (n=17,399)TBI (U) (n = 3,749) TBI (-) (n=11,794)TBI (+) (n=919)TBI (U) (n=225) TBI( -) (n=849) ClinicsMeanSDMeanSDMeanSDMeanSDMeanSDMeanSD TBI – related Polytrauma3.08.53.79.21.44.22.96.73.57.31.54.6 Physical Therapy2.8 e 7.03.17.81.9 d 6.53.2 e 7.35.217.72.4 d 6.7 TBI Clinic1.43.31.02.40.71.41.53.41.22.60.72.0 Mental Health Psychiatry- Psychology 1.34.31.75.31.14.61.55.02.510.11.57.0 PTSD6.214.58.316.84.710.96.314.98.413.65.413.0 Alcohol – Substance Abuse1.3 c 9.62.012.71.2 d 8.10.4 c 2.51.37.40.7 d 6.0 Other counseling1.1 c 3.71.34.30.85.90.8 c 2.41.33.20.72.4 Medical Specialties5.2 c 6.57.0 c 7.84.4 c 5.87.0 c 7.78.7 c 7.76.5 c 7.1 Total33.5 c 42.343.1 d 49.725.2 c 33.437.8 c 39.551.0 d 49.031.3 c 36.7 Differences in Utilization 12 months Post-CTE As seen in Table 1:  Average 12-month outpatient care averages were high (at least 25 visits for the year) for both genders and all TBI designations. Within Gender: Both men and women deemed to be TBI (-) had the least number of follow-up appointments across clinics. For male patients, amounts of outpatient care increased significantly from TBI (-) to TBI (+) to TBI (U) for all types of clinic visits. DISCUSSION