Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System

Objective

This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans.

Data Sources and Study Setting

Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules.

Study Design

We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state.

Data Collection Methods

Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available.

Principal Findings

Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed.

Conclusions

Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.     

Location of cancer surgery for older veterans with cancer

Objective

Many veterans undergo cancer surgery outside of the Veterans Health Administration (VHA). We assessed to what extent these patients obtained care in the VHA before surgery.

Data Sources

VHA-Medicare data, VHA administrative data, and Veterans Affairs Central Cancer Registry data.

Study Design

We identified patients aged ≥65 years in the VHA-Medicare cohort who underwent lung or colon cancer resection outside the VHA and assessed VHA visits in the year before surgery.

Principal Findings

Over 60% of patients in the VHA-Medicare cohort who received lung or colon cancer surgeries outside the VHA did not receive any care in VHA before surgery.

Conclusions

Veterans’ receipt of major cancer surgery outside the VHA probably reflects usual private sector care among veterans who are infrequent VHA users.     

Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services

Background  

Older veterans may use both the Veterans Health Administration (VHA) and Medicare, but the association of dual use with health outcomes is unclear. We examined the association of indirect measures of dual use with mortality.     

Local Leaders' Perspectives on Women Veterans’ Health Care: What Would Ideal Look Like?

Background

The Veterans Health Administration (VHA) faces challenges in providing comprehensive, gender-sensitive care for women. National policies have led to important advancements, but local leadership also plays a vital role in implementing changes and operationalizing national priorities. In this article, we explore the notions of ideal women veterans' health care articulated by women's health leaders at local VHA facilities and regional networks, with the goal of identifying elements that could inform practice and policy.

Bridging the Gap for Perinatal Veterans: Care by Mental Health Providers at the Veterans Health Administration

BackgroundPregnant women veterans receive maternity care from community obstetricians but continue to receive mental health care within the Veterans Health Administration (VHA). Our objective was to explore the experiences of VHA mental health providers with pregnant and postpartum veterans.MethodsMental health providers (n = 33) were identified at 14 VHA facilities across the United States. Semistructured interviews were conducted over the phone to learn about provider experiences with perinatal women veterans and their perceptions of depression screening and mental health treatment management for pregnant and postpartum veterans receiving mental health care within the VHA system.FindingsProviders identified an absence of screening protocols and referral procedures and variability in risk/benefit conversations surrounding psychotropic medication use as important areas of weakness for VHA mental health care during the perinatal period. Care coordination within facilities, primarily through Primary Care-Mental Health Integration teams, was identified as a main facilitator to promoting better mental health care for perinatal veterans.ConclusionsMental health providers caring for veterans during the perinatal period identified several areas where care could be improved, notably in screening and referral processes. A refinement to current guidelines to specify standard screening tools, screening schedules, and referral processes could potentially engage a greater number of pregnant women in VHA mental health care.     

Changes in veterans' use of outpatient care from 1992 to 2000

OBJECTIVES: During the mid-1990s, the Veterans Health Administration (VHA) reorganized and placed greater emphasis on high-quality primary care. To determine whether the reorganization was associated with changes in patterns of out-patient VHA use, we sought to evaluate changes in characteristics of veterans who use VHA outpatient services between 1992 and 2000. METHODS: We merged 2 waves of the National Survey of Veterans to determine changes in patterns of outpatient care use. We evaluated the extent to which veterans who received outpatient care received that care from the VHA. RESULTS: The odds ratio for VHA-only outpatient care relative to non-VHA-only care in 2000 relative to 1992 was 1.75 (95% confidence interval [CI]=1.51, 2.04), and the odds ratio for dual relative to non-VHA-only care was 1.22 (95% CI=1.08, 1.37). Veterans who were older, had low incomes, and had no additional health insurance coverage were most likely to increase their use of VHA outpatient care. CONCLUSIONS: Our results suggest that the VHA is increasingly serving veterans who have trouble accessing the private health care system.     

Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes?

Background  

Millions of veterans are eligible to use the Veterans Health Administration (VHA) and Medicare because of their military service and age. This article examines whether an indirect measure of dual use based on inpatient services is associated with increased mortality risk.     

Five-year Trends in Women Veterans' Use of VA Maternity Benefits, 2008–2012

BackgroundAn increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.ObjectiveThe goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.DesignWe undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.ParticipantsWe included pregnant veterans using VHA maternity benefits for delivery.Main MeasuresMeasures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.Key ResultsDuring the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).ConclusionsOver a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.     

Defining “Rural” for Veterans’ Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Rural Veterans’ Perspectives of Dual Care

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans’ satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.     

The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals

Background  

Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system.     

Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans

BackgroundApproximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.ObjectiveWe compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.MethodsCross-sectional data were drawn from an observational study of women veterans aged 45–64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.ResultsIn this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3–11.9).ConclusionsVHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.     

Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening

Objective

This study examined veterans'' responses to the Veterans Health Administration''s (VHA''s) universal screen for homelessness and risk of homelessness during the first 12 months of implementation.

Methods

We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen.

Results

More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability.

Conclusion

To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.Addressing homelessness among veterans is a top policy priority at the federal, state, and local levels. To this end, the U.S. Department of Veterans Affairs (VA) developed a comprehensive plan to prevent and end homelessness among veterans,¹ emphasizing prevention-oriented strategies and investing substantial resources in novel approaches, most notably the Supportive Services for Veteran Families (SSVF) program.² To date, these efforts have garnered notable success; the number of veterans experiencing homelessness on a given night nationwide declined from 74,050 to 55,779—a 24% decrease—from 2009 to 2013.³Identifying veterans who are at risk of homelessness—or are experiencing homelessness but are not accessing services through Veterans Health Administration (VHA) homeless programs—is crucially important for continued progress toward ending veteran homelessness. A recent study found that more than one-third of a cohort of newly homeless veterans used mainstream homeless assistance services but did not access VHA homeless programs, suggesting that a sizable number of veterans experiencing homelessness or risk of homelessness (hereinafter referred to as “risk”) may not be linked with VA resources that may improve their housing stability.⁴To improve the VA''s ability to identify these veterans and refer them appropriately, VHA implemented a universal, two-question screener for current homelessness and imminent risk—the Homelessness Screening Clinical Reminder (HSCR)—that is administered at all VHA health-care facilities. During the first three months of its implementation (October 1, 2012, to January 10, 2013), 0.9% of respondents reported current homelessness, 1.2% reported imminent risk, and 97.9% screened negative for both.⁵ However, this observation period was unable to account for known seasonal trends in the size of the homeless population⁶ and did not allow for an assessment of multiple responses to the HSCR, which would indicate subsequent changes in housing status over time. The present study builds on these findings, using data collected by the HSCR during its first year of implementation.The aims for this study were to (1) estimate the baseline annual prevalence rates of homelessness and risk among veterans who accessed VHA outpatient health care during federal fiscal year (FY) 2013, (2) measure changes in housing stability for veterans who initially screened positive and completed a follow-up screening during FY 2013 and identify factors associated with those changes, and (3) identify distinct risk profiles of veterans who are experiencing persistent housing instability.     

Veterans'' System-of-care Preferences for Percutaneous Transluminal Coronary Angioplasty in a Rural Setting

CONTEXT: In the Veterans Health Administration (VHA), regionalization of high-technology health care services may influence veterans who live far from referral centers to obtain care locally, through the private sector. PURPOSE: To understand veterans' system-of-care preferences for a high-technology regionalized service. METHODS: The charts of 142 veterans who were referred for percutaneous transluminal coronary angioplasty (PTCA) by their VHA cardiologists were reviewed. FINDINGS: Fifty-two percent of these veterans obtained the procedure outside the VHA system. Insurance coverage and out-of-pocket costs were strongly associated with veterans' obtaining PTCA outside of the VHA system; travel distance was not. CONCLUSIONS: As the VHA begins to understand veterans' use of multiple systems of care, it will be important to understand the relationship between out-of-pocket costs and the system of care used for high-technology health care services.     

Use of preventive care by elderly male veterans receiving care through the Veterans Health Administration, Medicare fee-for-service, and Medicare HMO plans

Objectives. We compared use of preventive care among veterans receiving care through the Veterans Health Administration (VHA), Medicare fee-for-service (FFS) plans, and Medicare health maintenance organizations (HMOs).Methods. Using both the Costs and Use, and Access to Care files of the Medicare Current Beneficiary Survey (2000–2003), we performed a cross-sectional analysis examining self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement among male veterans 65 years or older. Veterans’ care was categorized as received through VHA, Medicare FFS, Medicare HMOs, VHA and Medicare FFS, or VHA and Medicare HMOs.Results. Veterans receiving care through VHA reported 10% greater use of influenza vaccination (P<.05), 14% greater use of pneumococcal vaccination (P<.01), a nonsignificant 6% greater use of serum cholesterol screening (P=.1), and 15% greater use of prostate cancer screening (P<.01) than did veterans receiving care through Medicare HMOs. Veterans receiving care through Medicare FFS reported less use of all 4 preventive measures (P<.01) than did veterans receiving care through Medicare HMOs.Conclusions. Receiving care through VHA was associated with greater use of preventive care.The Veterans Health Administration (VHA) is the largest integrated public-sector health care system in the United States.1 Under a set of reforms in 1995 that emphasized increased use of information technology, performance measurement, and service integration, VHA has become a leader in delivering high-quality care to veterans.2^–6 One comprehensive cross-sectional study of 596 VHA patients and 992 community patients (older than 35 years) between 1997 and 2000 found that veterans treated at VHA scored significantly higher for overall quality of care, chronic disease care, and preventive care.7Previous research has also demonstrated that Medicare health maintenance organizations (HMOs) are superior to Medicare fee-for-service (FFS) plans in delivering preventive care to patients.8 Medicare HMOs can use health care management techniques such as performance measurement, data analysis, and care coordination to improve the efficiency and quality of care delivered to patients.9^,10 There are few studies, however, that have compared Medicare HMOs and VHA.11^,12 Only 1 study to date has compared the quality of care delivered by VHA to the care delivered by high-performing commercial managed-care programs.11 That study, which focused on diabetes, found that diabetes-related processes of care (e.g., eye examination and hemoglobin A_1C measurement) and 2 intermediate outcomes (targets for hemoglobin A_1C and low-density lipoprotein cholesterol) were more likely to be achieved for patients cared for in the VHA system than for patients cared for in commercial managed-care plans.In contrast to VHA, in which the strides in quality improvement have been relatively uniform across the 21 different Veterans Integrated Service Networks, there is large variation in the quality of care delivered by Medicare HMOs plans.13 This variation may be because of different organizational characteristics among plans. A plan can be structured as a staff-model organization, in which the plan owns the hospital and physicians are salaried, or as a loose financial arrangement between multiple providers in unrelated practice settings.10^,13 Previous research has identified 4 factors in high-performing managed-care programs that lead to the delivery of high-quality care: (1) a strong working relationship with the plan’s physicians; (2) quality-focused leadership, culture, and values; (3) a high-quality physician practice base in the delivery system; and (4) an emphasis on the use of data and analysis in clinical improvement.10^,14VHA has all 4 of these characteristics. It has strong local practice leadership, with emphasis on performance measurement and quality improvement; strong relationships with academic medical centers, which creates a high-quality physician practice base; and an electronic health record that facilitates use of data for clinical improvement. VHA is in effect a large managed-care organization caring for over 5 million veterans across the country.1^,15Our primary objective was to use pooled data on veterans from the Medicare Current Beneficiary Survey (MCBS) to compare the preventive care delivered to veterans in VHA with care delivered to veterans by Medicare HMO and FFS plans. Many elderly veterans, however, are eligible to receive care from both Medicare and VHA and can also use both programs simultaneously (dual users). Therefore, we also compared the preventive care received by veterans through dual use of these sources with care received through Medicare HMO plans. We focused on measures of preventive care because these measures have an important role in reducing morbidity and mortality in the elderly.16^–19     

An Unintended Consequence of Culture Change in VA Community Living Centers

Objective

Although a growing body of evidence suggests that culture change and its corollary, person-centered care improves resident outcomes in the nursing home setting, little is known about the effect of culture change in a postacute setting in which patients receive skilled nursing and rehabilitation services for a relatively short period of time before returning home.

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

Objectives. We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis.Methods. We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009–2011) of suicide-related events among all VHA users to examine suicide risk.Results. GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population.Conclusions. The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines gender identity disorder (GID) as having deeply rooted feelings of persistent discomfort with one’s current biological gender and having the desire to be of the opposite gender to the extent that “the disturbance causes clinically significant distress or impairment in … important areas of functioning.”1^(p260)Although the diagnosis is relatively rare, persons diagnosed with GID constitute a subpopulation of people who experience numerous disparities in physical and mental health as well as health care access.2 Although a precise estimate of GID occurrence among the general population is unknown, one theoretical framework (i.e., flight into hypermasculinity) posits that GID may be overrepresented in the military and among veterans,3 and there is support for this hypothesis in community-based samples of transgender persons in which high prevalence of military service is observed.4 Furthermore, there is evidence of elevated risk for suicidal behavior among transgender populations.5–10 However, prevalence of GID and suicide-related events (e.g., suicide planning, suicide attempt) have yet to be examined among veterans who have received Veterans Health Administration (VHA) services. We have addressed this unmet need.     

Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.     

Anticipating the Traumatic Brain Injury–Related Health Care Needs of Women Veterans After the Department of Defense Change in Combat Assignment Policy

BackgroundFemale service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI).MethodsThe article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE).FindingsBoth women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs.ConclusionAs women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting.