Rural-Urban Disparities in Health-Related Quality of Life Within Disease Categories of Veterans

ABSTRACT:  Context: Compared to their urban counterparts, rural veterans have been found to have lower health-related quality of life. Purpose: To determine whether these disparities persist when examining disease categories of rural and urban veterans. Methods: We obtained survey data on 748,216 veterans who were current or anticipated Veterans Health Administration patients. Using International Classification of Diseases (ICD)-9CM codes, we determined whether these veterans had diagnoses that fell into any of 30 physical health disease categories, and we used ZIP codes to determine whether veterans lived in rural or urban settings. We compared rural to urban prevalence of disease categories as well as urban to rural health-related quality-of-life physical health component summary scores (PCS) and mental health component summary scores (MCS) for each disease category. Findings: Physical diagnoses were significantly more prevalent in the rural veteran population for most disease categories examined. For every disease category examined, PCS were significantly lower for veterans who lived in rural, compared to urban, settings ( P < .001 for all); rural veterans also experienced lower MCS for all disease categories although differences were modest. Differences persisted after controlling for sociodemographic factors. Conclusions: Compared to the urban veteran population, within disease categories, the rural veteran population experiences higher disease prevalence and lower physical and mental quality-of-life scores. Policymakers should anticipate greater health care demands from the rural veteran population and work to meet that demand.     

Impact of Rural Residence on Survival of Male Veterans Affairs Patients After Age 65

Objectives: More than 1 in 5 Veterans Affairs (VA) users lives in a rural setting. Rural veterans face different barriers to health care than their urban counterparts, but their risk of death relative to their urban counterparts is unknown. The objective of our study was to compare survival between rural and urban VA users. Methods: We linked the Large Health Survey of Veteran Enrollees conducted in 1999 to the Veterans Administration vital status registry. We used time-to-event regression models controlling for patient race, education, ZIP-code median income, and marital and smoking status. Findings: Of the 372,463 male veterans of age 65 or greater, 80,931 lived in rural settings. Age-adjusted mortality was 5.9% higher (95% CI, 4.5%-7.2%) in rural residents compared to urban residents. After adjusting for age, education, and ZIP-code median income, rural residents had 3.0% lower mortality (95% CI, 1.5%-4.4%). Compared to urban and suburban VA users, rural VA users’ mortality at age 65 was 12% lower, but this advantage gradually diminished by age 75. Conclusion: Mortality after the age of 65 for male VA users is higher in rural dwellers than in urban dwellers. However, among veterans of the same socioeconomic characteristics, rural-dwelling veterans have up to 15% better mortality than urban-dwelling veterans until the age of 75.     

A Longitudinal Analysis of Rural and Urban Veterans’ Health-Related Quality of Life

Context: Cross-sectional studies have identified rural-urban disparities in veterans’ health-related quality-of-life (HRQOL) scores. Purpose: To determine whether longitudinal analyses confirmed that these disparities in veterans’ HRQOL scores persisted. Methods: We obtained data from the SF-12 portion of the veterans health administration's (VA's) Survey of Healthcare Experiences of Patients (SHEP) collected between 2002 and 2006. During that time, the SHEP was randomly administered to approximately 250,000 veterans annually who had used VA outpatient services. We evaluated 163,709 responses from veterans who had completed 2 or more surveys during the years studied. Respondents were classified into rural-urban groups using ZIP Code-based rural-urban commuting area designations. We estimated linear regression models using generalized estimating equations to determine whether rural and urban veterans’ HRQOL scores were changing at different rates over the time period examined. Findings: After adjustment for sociodemographic differences, we found that urban veterans had substantially better physical HRQOL scores than their rural counterparts and that these differences persisted over the study period. While urban veterans had worse mental HRQOL scores than rural veterans, those differences diminished over the time period studied. Conclusions: Rural-urban disparities in HRQOL scores persist when tracking veterans longitudinally. Reduced access among rural veterans to care may contribute to these disparities. Because rural soldiers are overrepresented in current conflicts, the VA should consider new models of care delivery to improve access to care for rural veterans.     

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.     

Trauma and Substance Use Disorders in Rural and Urban Veterans

Context: Disparities in the prevalence, morbidity, and mortality of multiple mental health conditions have been described between rural and urban populations. However, there is limited information regarding differences in exposure to trauma and trauma‐related mental health conditions in these populations. Given the number of veterans who are returning to rural communities after serving in Operation Enduring Freedom and Operation Iraqi Freedom, differences in trauma exposure are of particular relevance. Trauma exposure is related to a variety of mental health disorders including substance use disorders (SUD). Purpose: The objectives of this preliminary study were to describe lifetime military and nonmilitary trauma and to compare trauma history between rural and urban veterans in SUD treatment. Methods: Sixty adults in SUD treatment were enrolled at 3 Veterans Health Administration sites in Nebraska over a 3‐month period in 2008. Subjects completed an interview with study staff, which assessed SUD diagnoses and childhood, lifetime, and military trauma. Rural or urban status was determined by self‐report of childhood residence. Childhood trauma, lifetime trauma, and response to military trauma were compared between rural and urban veterans. Findings: Although there were no significant differences in trauma exposure between rural and urban groups, there was an association between specific types of trauma and measures typically associated with increased substance abuse severity and poorer SUD treatment outcome. Conclusion: This is the first study, to our knowledge, which compared trauma exposure between rural and urban veterans and identified an association between childhood trauma exposure and multiple SUD treatment attempts.     

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.     

Echocardiogram Utilization Among Rural and Urban Veterans

Purpose: To compare echocardiography use among urban and rural veterans and whether differences could be accounted for by distance. Methods: We used Veterans Administration (VA) administrative data from 1999 to 2007 to identify regular users of the VA Healthcare System (VA users) who did and did not receive echocardiography. Each veteran was categorized as residing in urban, rural or highly rural areas using RUCA codes. Poisson regression was used to compare echocardiography utilization rates among veterans residing in each area after adjusting for demographics, comorbidities, clustering of patients within VA networks and distance to the nearest VA medical center offering echocardiography. Findings: Our study included 22.7 million veterans of whom 1.3 million (5.7%) received at least 1 echocardiogram. Of echocardiography recipients, 69.2% lived in urban, 22.0% in rural and 8.8% in highly rural areas. In analyses adjusting for patient demographics, comorbidities, and clustering, utilization of echocardiography was modestly lower for highly rural and rural veterans compared with urban veterans (42.0 vs 40.1 vs 43.1 echocardiograms per 1,000 VA users per year for highly rural, rural and urban, respectively; P < .001). After further adjusting for distance, echocardiography utilization was somewhat higher for veterans in highly rural and rural areas than it was for urban areas (44.9 vs 41.8 vs 40.8 for highly rural, rural and urban, respectively; P < .001). Conclusions: Echocardiography utilization among rural and highly rural veterans was marginally lower than for urban veterans, but these differences can be accounted for by the greater distance of more rural veterans from facilities offering echocardiograms.     

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.     

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.     

Practical and Policy Implications of Using Different Rural-Urban Classification Systems: A Case Study of Inpatient Service Utilization Among Veterans Administration Users

ABSTRACT:  Context: Several classification systems exist for defining rural areas, which may lead to different interpretations of rural health services data. Purpose: To compare rural classification systems on their implications for estimating Veterans Administration (VA) utilization. Methods: Using 7 classification systems, we counted VA health care enrollees who lived in each category, and number admitted to VA hospitals or non-VA hospitals under Medicare. For dual VA-Medicare enrollees over age 65, we compared VA and private sector hospitalizations on numbers of admissions and bed-days of care. We compared VA enrollees' relative proportions across rural to urban categories for each classification system and evaluated discordance between systems at the veterans-integrated service networks (VISN) level. Findings: Enrollment and inpatient utilization counts for rural veterans vary considerably from one classification system to another, though the systems generally agree that admission rates, length of stay, and reliance on the VA for care are lower for rural veterans. Among older dual VA and Medicare enrollees, rural residents rely on non-VA facilities more, though this effect also varies widely depending on the classification scheme. VISNs vary greatly in the proportions of patients who are rural residents, and in the degree to which classification systems are discordant in designating patients as rural. Conclusions: Decisions about allocating VA health care resources to target "rural" patients may be affected greatly by the rural classification system chosen, and the impact of this choice will affect some hospital networks much more than others.     

Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.Emerging research with US veterans of Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq suggests that the mental health effects of these deployments are significant. An estimated 19% to 42% of this population have mental health conditions.^1–4 One of the potential contributors to this burden of mental illness is exposure to sexual assault or harassment during service, referred to within the Veterans Health Administration as military sexual trauma.⁵ Considerable data attest to the negative mental health consequences of such experiences in both military and civilian populations,^5–13 yet no data investigating military sexual trauma in the context of postdeployment mental health among the Operation Enduring Freedom and Operation Iraqi Freedom cohort are currently available.Operation Enduring Freedom and Operation Iraqi Freedom veterans are eligible for 5 years of free care through the Veterans Health Administration for conditions related to their military service. This cohort is turning to the Veterans Health Administration for health care in record numbers, with nearly 40% enrolled to date.¹⁴ The Veterans Health Administration has recently invested significant resources in the detection and treatment of military sexual trauma, implementing universal military sexual trauma screening in 2002 and providing free care for all related conditions.⁵ Although military sexual trauma had been documented in veterans of previous war eras,^15,16 Operation Enduring Freedom and Operation Iraqi Freedom veterans are the first generation of Veterans Health Administration users to return from a large-scale deployment to these comprehensive screening and treatment services.For our study, we completed, to our knowledge, the first national, population-based assessment of the mental health profile associated with a history of military sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans who used Veterans Health Administration services. We describe the prevalence of military sexual trauma and characterized the postdeployment mental health conditions among patients who reported a history of military sexual trauma.     

Children's mental health care: differences by race/ethnicity in urban/rural areas

This study examines racial/ethnic disparities in children's mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.     

Partnering with communities to address the mental health needs of rural veterans

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups—clergy, postsecondary educators, and criminal justice personnel—are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center‐based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2‐hour workshop and an intensive 2.5‐day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.     

Mental Health Clinician and Community Clergy Collaboration to Address Moral Injury in Veterans and the Role of the Veterans Affairs Chaplain

Moral injury in veterans with posttraumatic stress disorder includes symptoms of guilt and shame, and these symptoms are often not responsive to evidence-based mental health treatments. Clergy provide a pathway for relieving the guilt and shame. However, there is a long history of mistrust between clergy and mental health clinicians and not enough Veterans Health Administration chaplains to meet this need. The goal of this study was to gather qualitative interview data from relevant stakeholders regarding whether and how Veterans Affairs (VA) mental health clinicians and community clergy could collaborate to address moral injury issues such as guilt and shame in veterans being treated for posttraumatic stress disorder. The stakeholders for this study were veterans, mental health clinicians, and clergy. Qualitative data were organized into three domains: barriers, facilitators, and intervention suggestions. These data were used to develop a new intervention for moral injury that includes a central role for the Veterans Affairs chaplain.     

The Impact of Living in Rural and Urban Areas: Vitamin D and Medical Costs in Veterans

Purpose: Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural‐urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization. Methods: Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural. Findings: The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization. Conclusions: Vitamin D deficiency may be an additional health disparity experienced by both rural and inner‐city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.     

Veterans using and uninsured veterans not using Veterans Affairs (VA) health care

OBJECTIVES: The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans. METHODS: The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured. RESULTS: Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year. CONCLUSIONS: Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.     

Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care

Objective. To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.
Data Source. Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.
Study Design. Retrospective, cross-sectional analysis.
Data Collection/Extraction Methods. Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).
Results. VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.
Conclusions. VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.     

Utilization and Intensity of Outpatient Care Related to Military Sexual Trauma for Veterans from Afghanistan and Iraq

Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.     

Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger Than 65 Years

CONTEXT: The 4.5 million military veterans treated by the Veterans Health Administration (VA) are believed to experience poorer physical and mental health than nonveterans. Furthermore, nonmetropolitan residents have less access to medical services, whether or not they are veterans in VA care. A direct comparison of metropolitan and nonmetropolitan veterans and nonveterans on a national health survey has not been reported, so it is not known whether nonmetropolitan VA patients experience similar medical need or access as other nonmetropolitan residents. PURPOSE: We sought to compare the perceptions of health status and access to care among metropolitan and nonmetropolitan veterans in VA care, other veterans, and nonveterans in a large national sample surveyed under the same conditions. METHODS: Male respondents to the 2000 Behavioral Risk Factor Surveillance System health survey were divided into veterans or nonveterans, VA users or nonusers, metropolitan or nonmetropolitan residents, and 1 of 3 age groups (18-44, 45-64, and 65(+)). Responses to questions about current health status, health coverage, and access to care were submitted to chi-square analyses or analyses of variance, using SUDAAN software to compute survey error variance. FINDINGS: Nonmetropolitan VA patients younger than 65 years consistently reported the worst physical and mental health status and reduced access to care. CONCLUSIONS: VA can anticipate increasing demand for mental and physical health care among rural veterans younger than 65 years.