Creating a sampling frame for population-based veteran research: representativeness and overlap of VA and Department of Defense databases

Most veteran research is conducted in Department of Veterans Affairs (VA) healthcare settings, although most veterans obtain healthcare outside the VA. Our objective was to determine the adequacy and relative contributions of Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and Department of Defense (DOD) administrative databases for representing the U.S. veteran population, using as an example the creation of a sampling frame for the National Survey of Women Veterans. In 2008, we merged the VHA, VBA, and DOD databases. We identified the number of unique records both overall and from each database. The combined databases yielded 925,946 unique records, representing 51% of the 1,802,000 U.S. women veteran population. The DOD database included 30% of the population (with 8% overlap with other databases). The VHA enrollment database contributed an additional 20% unique women veterans (with 6% overlap with VBA databases). VBA databases contributed an additional 2% unique women veterans (beyond 10% overlap with other databases). Use of VBA and DOD databases substantially expands access to the population of veterans beyond those in VHA databases, regardless of VA use. Adoption of these additional databases would enhance the value and generalizability of a wide range of studies of both male and female veterans.     

Disability and treatment patterns of multiple sclerosis patients in United States: a comparison of veterans and nonveterans

The Veterans Health Administration (VHA) is the largest integrated healthcare system in the world and provides care to approximately 20,000 multiple sclerosis (MS) patients. Here, we report that these MS patients are disproportionately more likely to be older, male, unemployed, and disabled with lower levels of education and financial resources when compared to veterans not receiving care within the VHA or to nonveteran MS patients. When comparing the VHA MS patients to a cohort of nonveteran MS patients matched for age, sex, and disability, we found that veterans receiving care within the VHA were equally likely to have received care from a neurologist and more likely to have received care from rehabilitation specialists and primary care physicians than nonveterans. Similarly, veterans in the VHA were more likely to receive therapy with certain symptomatic medications but were less likely to be treated with disease-modifying agents for MS (DMAMS) than nonveterans. When treated with DMAMS, they are more likely to be treated with Avonex and significantly less likely to receive treatment with Copaxone or Novantrone.     

Health care coverage and access to care: the status of Minnesota's veterans

OBJECTIVES: The primary objective of this study was to examine veterans' reliance on health care services provided by the Veterans Health Administration (VHA) within Minnesota and estimate the potential effect on uninsurance rates if all eligible veterans relied on VHA coverage. Secondary objectives were to compare veterans and nonveterans' by geographic location, demographic characteristics, health status, and health insurance coverage and to compare insured and uninsured veterans especially with regard to access to care. RESEARCH DESIGN: Data are from the 2001 Minnesota Health Access Survey of a stratified random sample of more than 27,000 respondents, of whom 3,500 were self-identified veterans. Although all veterans were eligible to obtain health care services from the VHA in 2001, veterans not reporting VHA coverage and having no other source of insurance coverage were considered uninsured. Differences in weighted population characteristics are reported. Logistic regression analysis is used to identify factors associated with veterans' reliance on VHA coverage. RESULTS: Veterans represented 13.4% of the state's adult population and 9.3% of the state's uninsured nonelderly adult population in 2001. Uninsured veterans were more likely to be single, unemployed, living in rural areas, and reporting constrained access to services than insured veterans. Veterans with a non-VHA source of insurance were less reliant on VHA services. CONCLUSIONS: The state's uninsurance rate would significantly decrease if VHA capacity constraints were alleviated and veterans relied on the VHA safety net. If veterans' insurance status matters in states with low uninsurance rates, VHA coverage has broader implications for states with higher veteran concentrations and higher uninsurance rates.     

Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system

The improved management of pain among veterans seeking care in Veterans Health Administration (VHA) facilities has been established as a priority. This study documents the high prevalence of reports of pain among a convenience sample of 685 veterans seeking care in a VHA primary care setting. Also reported are associations of pain complaints with self-rated health, an index of emotional distress, health-risk behaviors such as tobacco and alcohol use, health-related concerns about diet and weight, and perceptions of the availability of social support. The relationship between the presence of pain and use of outpatient and inpatient medical and mental health services is also examined. Nearly 50% of the sample reported that they experience pain regularly and that they were concerned about this problem at the time of the index visit to their primary care provider. Persons acknowledging the presence of pain, relative to those not reporting pain, were younger, reported worsening health over the past year, had greater emotional distress, used tobacco, had diet and/or weight concerns, and were found to use more outpatient medical, but not inpatient medical or mental health services. Results support the goals of the VHA National Pain Management Strategy designed to reduce unnecessary pain and suffering among veterans receiving care in VHA facilities.     

Inpatient mortality of hip fracture patients in the Veterans Health Administration.

Hip fractures among elderly people frequently result in permanent disabilities, nursing home placement, and death. The bulk of hip fracture research focuses on elderly women. Within the Veterans Health Administration (VHA), the majority of patients are men. There are no published national reports on hip fractures with large male samples, or on related inpatient mortality among veterans. This retrospective study of 13,546 veterans with hip fracture discharges from 1998-2002 found unadjusted mortality rates are higher in the VHA, compared with the general population. VHA patients tend to be older men in poor health who stay in the hospital longer Increased knowledge about the risks and outcomes associated with hip fractures in men could lead to improved primary and secondary injury-prevention programs. Rehabilitation nurses in acute care can be catalysts in proactively incorporating protective devices, screening for osteoporosis, and initiating lifestyle changes in their plans of care to optimize outcomes for hip fracture patients.     

Female veterans' use of health care services

The number of female veterans has more than doubled in the last 15 years, and this growth is expected to continue. This study examines the current utilization of both overall and Veterans Administration (VA) health care services by female veterans. Current utilization is studied as a set of contact decisions: whether or not to utilize any inpatient, VA inpatient, any outpatient, and VA outpatient services. Probit regression is used to estimate these dichotomous choices. Results indicate that health status and some demographic variables are significantly related to the use of all four types of care. In addition, use of other VA benefits, the absence of private insurance coverage, and low income are predictors of use of the VA.     

Health Care Resource Utilization and Costs Associated with Transitioning to 3-month Paliperidone Palmitate Among US Veterans

Purpose

The aim of this article was to describe and compare treatment patterns, health care resource utilization (HRU), and health care costs before and after transition in veterans with schizophrenia who were transitioned from paliperidone palmitate given once monthly (PP1M) to paliperidone palmitate given every 3 months (PP3M) according to prescribing-information guidelines.

Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States

Background: Significant gender disparities exist in life expectancy and major disease morbidity. There is a need to understand the major issues related to men’s health that contributes to these significant disparities. It is hypothesized that, high‐risk behaviors and low utilization of all and preventive health services contribute to the higher mortality and the higher and earlier morbidity in men. Methods: Data was collected from CDC: Health United States, 2007; Health Behavior of Adults: United States 2002–04; and National Ambulatory Medical Care Survey: 2005 Summary. Results: In United States, men are more likely to be regular and heavy alcohol drinkers, heavier smokers who are less likely to quit, non‐medical illicit drug users, and are more overweight compared to women. Men are less likely to utilize health care visits to doctor’s offices, emergency departments (ED), and physician home visits than women. They are also less likely to make preventive care, hospice care, dental care visits, and have fewer hospital discharges and shorter hospital stays than women. Conclusions: High‐risk behaviors and low utilization of health services may contribute to the lower life expectancy in men. In the context of public health, behavioral and preventive interventions are needed to reduce the gender disparity.     

Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument

BACKGROUND: Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. OBJECTIVE: To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. RESEARCH DESIGN: Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. SUBJECTS: 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. METHODS: We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. RESULTS: The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. CONCLUSIONS: The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.     

What can Medicaid data add to research on VA patients?

This article is the first to describe Department of Veterans Affairs (VA) patients' use of Medicaid at a national level. We obtained 1999 national VA enrollment and utilization data, Centers for Medicare and Medicaid Services enrollment and claims, and Medicare information from the VA Information Resource Center. The research team created files for program characteristics and described the VA-Medicaid dually enrolled population, healthcare utilization, and costs. In 1999, VA-Medicaid dual enrollees comprised 10.2% of VA's annual patient load (350,000/3,450,000); 304,000 were veterans. These veterans differed marginally from VA's veteran patients, being on average half a year younger and having 1% fewer males. Dual enrollees with mental health diagnoses and care were almost three times as numerous as long-term care patients; these two groups accounted for ~60% of dual enrollees. Dual enrollees disproportionately included housebound veterans and veterans needing aid and assistance. Half the dual enrollees had 12 months of Medicaid eligibility, and total Federal expenditures per patient not in managed care programs averaged >$18,000 (median >$6,000). Dually enrolled women veterans cost ~55% less than men. Medicaid benefits complement VA and are more accessible in many states. VA researchers need to consider including Medicaid utilization and costs in their studies if they target populations or programs related to long-term care or mental disorders.     

Suicide After Stroke in the United States Veteran Health Administration Population

ObjectiveTo evaluate risk for suicide among veterans with a history of stroke, seeking care within the Veterans Health Administration (VHA), we analyzed existing clinical data.DesignThis retrospective cohort study was approved and performed in accordance with the local Institutional Review Board. Veterans were identified via the VHA's Corporate Data Warehouse. Initial eligibility criteria included confirmed veteran status and at least 90 days of VHA utilization between fiscal years 2001-2015. Cox proportional hazards models were used to assess the association between history of stroke and suicide. Among those veterans who died by suicide, the association between history of stroke and method of suicide was also investigated.SettingVHA.ParticipantsVeterans with at least 90 days of VHA utilization between fiscal years 2001-2015 (N=1,647,671). Data from these 1,647,671 veterans were analyzed (1,405,762 without stroke and 241,909 with stroke).InterventionsNot applicable.Main Outcome MeasuresSuicide and method of suicide.ResultsThe fully adjusted model, which controlled for age, sex, mental health diagnoses, mild traumatic brain injury, and modified Charlson/Deyo Index (stroke-related diagnoses excluded), demonstrated a hazard ratio of 1.13 (95% confidence interval, 1.02-1.25; P=.02). The majority of suicides in both cohorts was by firearm, and a significantly larger proportion of suicides occurred by firearm in the group with stroke than the cohort without (81.2% vs 76.6%).ConclusionsFindings suggest that veterans with a history of stroke are at increased risk for suicide, specifically by firearm, compared with veterans without a history of stroke. Increased efforts are needed to address the mental health needs and lethal means safety of veterans with a history of stroke, with the goal of improving function and decreasing negative psychiatric outcomes, such as suicide.     

Use of administrative data to risk adjust amputation rates in a national cohort of medicare-enrolled veterans with diabetes

BACKGROUND: A reduction in diabetes-related lower extremity amputations is a national health care priority. OBJECTIVE: To develop a risk adjustment model for total amputation rates, using claims data. RESEARCH DESIGN: A retrospective longitudinal cohort analysis of veteran clinical users of the Veterans Health Administration (VHA)--Veterans with diabetes who were Medicare nonhealth maintenance organization enrolled in 1997 or 1998. Baseline risks ascertained in 1997 to 1998 were used to adjust Veterans Integrated Service Networks (VISN) amputation rates in 1999. MEASURES: Individual-level amputation outcome in VHA and private hospitals in 1999; VISN-level amputation rates adjusted for age, gender, race, foot risk factors, and macro- and microvascular complications; and rankings of 22 VISNs on amputation rates. RESULTS: A total of 218,528 patients incurred 3077 (14.1 per 1000) amputations in 1999, with 10.6 to 18.0 amputations per 1000 across 22 VISNs. Age, gender, race, prior amputation, infections, ulcers, peripheral vascular disease, and vascular complications were significant independent predictors of amputation (R = 0.20); demographic variables accounted for < 1% of the variance. The C statistic of the final model was 0.83. VISN rankings using age-, gender-, and race-adjusted rates were not substantially altered compared with rankings using the full risk-adjusted model (Spearman rank correlation, 0.85). CONCLUSION: Addition of foot risk and comorbidity variables increased the discrimination of a predictive model for total amputations in an elderly, largely male population of veterans with diabetes compared with use of demographic data alone. The authors suggest that this model be validated in other settings with availability of individual-level claims data.     

Effect of Post-traumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs Traumatic Brain Injury Model Systems Study

ObjectiveTo examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA).DesignMultivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data.SettingFive VA PRCs.ParticipantsVA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717).InterventionsN/A.Main Outcome MeasuresTotal, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals.ResultsA total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse.ConclusionsThis study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.     

The Identification and Management of Military Sexual Trauma in Veterans: Ask the Question!

Military sexual trauma (MST) is a serious and pervasive problem in the US military and results in the occurrence of physical, psychological, and psychosocial negative health consequences in female and male veterans. The prevalence of MST is increasing, and more veterans are seeking health care outside of the Veteran Affairs Medical Centers (VHA). Consequently, nurse practitioners as non-VHA health care providers may treat this population in the community. Insufficient knowledge precludes the ability to identify and manage MST. This article provides NPs with information for accurately identifying and managing military sexual trauma in the military and veteran population.     

Mental illness-related disparities in length of stay: algorithm choice influences results

Methodological challenges arise when one uses various Veterans Health Administration (VHA) data sources, each created for distinct purposes, to characterize length of stay (LOS). To illustrate this issue, we examined how algorithm choice affects conclusions about mental health condition (MHC)-related differences in LOS for VHA patients with diabetes nationally (n = 784,321). We assembled a record-level database of all fiscal year (FY) 2003 inpatient care. In 10 steps, we sequentially added instances of inpatient care from various VHA sources. We processed databases in three stages, truncating stays at the beginning and end of FY03 and consolidating overlapping stays. For patients with MHCs versus those without MHCs, mean LOS was 17.7 versus 13.6 days, respectively (p < 0.001), for the crudest algorithm and 37.2 versus 21.7 days, respectively (p < 0.001), for the most refined algorithm. Researchers can improve the quality of data applied to VHA systems redesign by applying methodological considerations raised by this study to inform LOS algorithm choice.     

Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions

BACKGROUND: Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. OBJECTIVES: We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. METHODS: Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. RESULTS: In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results. CONCLUSIONS: Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.