Gender Differences in service connection for PTSD

BACKGROUND: Mentally ill female veterans obtain a smaller proportion of their care from Department of Veterans Affairs (VA) facilities than mentally ill male veterans do, possibly because women are less likely than men to be service connected for psychiatric disabilities. "Service connected" veterans have documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the VA healthcare system. OBJECTIVES: To see if there are gender discrepancies in rates of service connection for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could be attributed to appropriate subject characteristics (eg, differences in symptom severity or impairment). RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SUBJECTS: Randomly selected veterans seeking VA disability benefits for PTSD. Women were oversampled to achieve a gender ratio of 1:1. RESULTS: A total of 3337 veterans returned usable surveys (effective response rate, 68%). Men's unadjusted rate of service connection for PTSD was 71%; women's, 52% (P < 0.0001). Adjustment for veterans' PTSD symptom severity or functional impairment did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of combat exposure did. Estimated rates of service connection were 53% for men and 56% for women after adjusting for combat exposure. This combat preference could not be explained by more severe PTSD symptoms or greater functional impairment. CONCLUSIONS: Instead of a gender bias in awards for PTSD service connection, we found evidence of a combat advantage that disproportionately favored men. The appropriateness of this apparent advantage is unclear and needs further investigation.     

Regional variation and other correlates of Department of Veterans Affairs Disability Awards for patients with posttraumatic stress disorder

BACKGROUND: Minnesota, Minneapolis, Minnesota. Posttraumatic stress disorder (PTSD) is a chronic disabling condition affecting more than 600,000 United States veterans and is the most common psychiatric condition for which veterans seek Veterans Affairs disability benefits. Receipt of such benefits enhances veterans' access to Veteran Affairs health care and reduces their chance of poverty. OBJECTIVES: We sought to determine whether previously identified regional variations in PTSD disability awards are explained by appropriate subject characteristics (eg, differences in PTSD symptomatology or dysfunction) and to estimate the impact of veterans' PTSD symptom severity or level of dysfunction on their odds of obtaining PTSD disability benefits. RESEARCH DESIGN: We used a mailed survey linked to administrative data. SUBJECTS: Subjects included 4918 representative, eligible men and women who filed PTSD disability claims between 1994 and 1998. RESULTS: A total of 3337 veterans returned useable surveys (68%). Before adjustment, PTSD disability claims approval rates ranged from 43% to 75% across regions. After adjustment, rates ranged from 33% to 72% (P <0.0001). Severer PTSD symptoms were associated with greater odds of having PTSD disability benefits (P <0.0001). Unexpectedly, poorer functional status was associated with lower odds of having benefits (P <0.0001). On average, clinical differences between veterans who did and did not have PTSD disability benefits were small but suggested slightly greater dysfunction among those without benefits. CONCLUSIONS: An almost twofold regional difference in claims approval rates was not explained by veterans' PTSD symptom severity, level of dysfunction, or other subject-level characteristics. Veterans who did not obtain PTSD disability benefits were at least as disabled as those who did receive benefits.     

Design of Department of Veterans Affairs Cooperative Study no. 420: group treatment of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a significant problem for a large number of veterans who receive treatment from the Department of Veterans Affairs (VA) health-care system. VA Cooperative Study 420 is a randomized clinical trial of group psychotherapy for treating PTSD among veterans who sought VA care. Participants at ten sites were randomly assigned to receive one of the two treatments: active treatment that embedded exposure therapy in a group context or comparison treatment that avoided trauma focus and instead addressed current interpersonal problems. Treatment was delivered weekly to groups of six participants for 30 weeks, followed by five monthly booster sessions. Follow-up assessments were conducted at the end of treatment (7 months) and the end of boosters (12 months) for all participants. Long-term follow-up data were collected for a subset of participants at 18 and 24 months. The primary outcome is PTSD severity; other symptoms, functional status, quality of life, physical health, and service utilization also were assessed. Data analysis will account for the clustering introduced by the group nature of the intervention. The pivotal comparison was at the end of treatment. Analyses of subsequent outcomes will concentrate on the question of the durability of effects. The study provides an example of how to address the unique challenges posed by multisite trials of group psychotherapy through attention to methodological and statistical issues. This article discusses these challenges and describes the design and methods of the study. Control Clin Trials 2001;22:74-88     

Posttraumatic stress disorder and employment in veterans participating in Veterans Health Administration Compensated Work Therapy

Few studies have examined employment outcomes in individuals with a primary diagnosis of posttraumatic stress disorder (PTSD). The current study used multivariate modeling to examine the relationship between PTSD, other aspects of military service, and employment among 5,862 veterans in a national Department of Veterans Affairs (VA) vocational rehabilitation program. Veterans with PTSD were 19% less likely to be employed at discharge (odds ratio = 0.81, p = 0.02) after controlling for potentially confounding variables. Individuals with substance use diagnoses or who were homeless at program entry were more likely to be employed at discharge, while receipt of public support income and severe mental illness decreased the likelihood of being competitively employed. This study supports current VA efforts to expand and improve the effectiveness of vocational rehabilitation services for veterans with PTSD.     

Validation of the French version of the brief pain inventory in Canadian veterans suffering from traumatic stress

Although pain is a significant clinical problem in individuals suffering from post-traumatic stress disorder (PTSD), reliable and valid measures of pain for this population are lacking. The goal of this study was to validate the Brief Pain Inventory (BPI) in French-speaking veterans suffering from PTSD (n = 130). We administered the BPI, as well as measures of PTSD, health status, quality of life, and social desirability, to veterans being assessed or treated for PTSD at a Veterans Affairs Canada clinic. The BPI showed strong internal consistency, as evidenced by Cronbach's alphas of 0.90 and 0.92 for the severity and interference subscales, respectively. Similar to previous findings, a two-factor structure (pain severity and pain interference) was found using an exploratory factor analysis. The two factors explained nearly 73% of the variance of the instrument. The BPI was also strongly correlated with health status and quality of life in the physical domain. In this veteran sample, nearly 87% of the veterans suffered from significant current pain. Veterans in our sample reported rates of pain severity that were similar to or higher than most of those reported by cancer patients and others with significant physical disability/illness. Overall, the French version of the BPI is a reliable, valid measure of pain in PTSD-suffering populations. Pain is a major issue in veterans with PTSD, and should be screened for with instruments such as the BPI.     

Structural equation modeling of associations among combat exposure, PTSD symptom factors, and Global Assessment of Functioning

This study used structural equation modeling (SEM) to evaluate the relative strength of associations between combat exposure, four posttraumatic stress disorder (PTSD) symptom factors, and functional impairment as indexed by Global Assessment of Functioning (GAF) scores in a sample of 315 veterans assessed at a Department of Veterans Affairs PTSD clinic. Results showed that the association between combat exposure and GAF scores was fully mediated by PTSD severity. The best-fitting model included direct paths from combat exposure to reexperiencing symptoms and from avoidance and numbing symptoms to GAF. However, only 17% of variance in GAF was accounted for by PTSD. The results raise concern about the use of the GAF score as a benchmark for quantifying combat PTSD-related functional impairment.     

Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores

Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.     

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care

ObjectivesPost-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care.MethodsA cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression.ResultsWe identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis.ConclusionPost-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.     

Characteristics associated with participation in DNA banking: The National Registry of Veterans with ALS

OBJECTIVE: Characteristics that may influence participation in DNA banks are not well defined. The purpose of this study was to examine characteristics associated with participation in a DNA bank among veterans diagnosed with Amyotrophic Lateral Sclerosis (ALS). METHODS: Veterans who screened eligible for the National Registry of Veterans with ALS were initially contacted about the DNA Bank via telephone and then mailed a consent form. Registry participants were then categorized as consented for the DNA bank, actively refused, or passively refused (consent form not returned after >3 months and multiple reminders). The associations of consent status with age, gender, race, military branch, years of military service, VA health system use, and ALS Functional Rating Scale (ALSFRS) scores were examined. RESULTS: Registry participants (N=1020) were 98% male, 9.5% non-white, and the mean age was 64.1 years. 61.1% of participants were current VA health system users, and the branches of service were: Army (46.1%), Navy (22.1%), Air Force (23.2%), and Marines (8.3%). A total of 14.7% of Registry participants refused DNA banking (9.4% active refusal, 5.3% passive refusal). Results from multivariable models indicated participants who were non-White, VA users, or had lower ALSFRS scores (reflecting poorer function) had higher odds of refusal. Race and VA use were associated with active refusal, while age and ALSFRS score were associated with passive refusal. CONCLUSION: Although the overall refusal rate for DNA banking was relatively low, we still found important differences in consent by race, VA use, and functional status in this cohort of veterans with ALS. Because differential participation in DNA banking may influence generalizability, further efforts are needed to understand and intervene to reduce these differences.     

Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

BackgroundThe health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.ObjectiveThis study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.DesignAn observational study was conducted using national VA administrative data from 2016 to 2019.ParticipantsData on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.Main measuresHomelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).Key resultsThe most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22–24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans. Conclusions: These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.     

Differences in cause of death of Washington State veterans who did and did not use Department of Veterans Affairs healthcare services

Relatively little is known about the cause of death in the veteran population, although more is known about the cause of death in Vietnam veterans or veterans receiving mental health services. This article compares characteristics and causes of death in Washington State veterans who did and did not use Department of Veterans Affairs (VA) healthcare services in the 5 years prior to death. This study included 62,080 veterans who died between 1998 and 2002, of whom 21% were users of VA healthcare services. The veterans who used VA healthcare services were younger, more often men, less educated, more often divorced, and more often smokers than the veterans who did not use VA healthcare services. Both female and male veterans who used VA healthcare services were more likely to die from drug- and/or alcohol-related causes. These findings suggest that the VA patient population is socially disadvantaged and more severely affected by substance-use disorders compared with veterans who do not use VA healthcare services.     

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.     

A spiritually based group intervention for combat veterans with posttraumatic stress disorder: feasibility study.

PURPOSE: To assess the feasibility, effect sizes, and satisfaction of mantram repetition -- the spiritual practice of repeating a sacred word/phrase throughout the day -- for managing symptoms of posttraumatic stress disorder (PTSD) in veterans. DESIGN: A two group (intervention vs. control) by two time (pre- and postintervention) experimental design was used. METHODS: Veterans were randomly assigned to intervention (n = 14) or delayed-treatment control (n = 15). Measures were PTSD symptoms, psychological distress, quality of life, and patient satisfaction. Effect sizes were calculated using Cohen's d. FINDINGS: Thirty-three male veterans were enrolled, and 29 (88%) completed the study. Large effect sizes were found for reducing PTSD symptom severity (d = -.72), psychological distress (d = -.73) and increasing quality of life (d = -.70). CONCLUSIONS: A spiritual program was found to be feasible for veterans with PTSD. They reported moderate to high satisfaction. Effect sizes show promise for symptom improvement but more research is needed.     

Brief report: Comparison of methods to identify Iraq and Afghanistan war veterans using Department of Veterans Affairs administrative data

The Department of Veterans Affairs (VA) has made treatment and care of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans a priority. Researchers face challenges identifying the OIF/OEF population because until fiscal year 2008, no indicator of OIF/OEF service was present in the Veterans Health Administration (VHA) administrative databases typically used for research. In this article, we compare an algorithm we developed to identify OIF/OEF veterans using the Austin Information Technology Center administrative data with the VHA Support Service Center OIF/OEF Roster and veterans' self-report of military service. We drew data from two different institutional review board-approved funded studies. The positive predictive value of our algorithm compared with the VHA Support Service Center OIF/OEF Roster and self-report was 92% and 98%, respectively. However, this method of identifying OIF/OEF veterans failed to identify a large proportion of OIF/OEF veterans listed in the VHA Support Service Center OIF/OEF Roster. Demographic, diagnostic, and VA service use differences were found between veterans identified using our method and those we failed to identify but who were in the VHA Support Service Center OIF/OEF Roster. Therefore, depending on the research objective, this method may not be a viable alternative to the VHA Support Service Center OIF/OEF Roster for identifying OIF/OEF veterans.     

Posttraumatic Cognitions and Suicidal Ideation Among Veterans Receiving PTSD Treatment

With approximately 20 veteran suicide deaths per day, suicidal ideation (SI) among veterans is an important concern. Posttraumatic stress disorder (PTSD) is associated with SI among veterans, yet mechanisms of this relationship remain unclear. Negative posttraumatic cognitions contribute to the development and maintenance of PTSD, yet no studies have prospectively examined the relationship between posttraumatic cognitions and SI. Veterans (N?=?177; 66% Male) participating in a 3-week intensive outpatient program for PTSD completed assessments of PTSD severity, depressive symptoms, SI, and posttraumatic cognitions. Negative posttraumatic cognitions about the self significantly predicted SI at posttreatment, controlling for pretreatment levels of SI, depression, and PTSD symptom severity. Self-blame and negative posttraumatic cognitions about others/world did not predict SI prospectively. Negative posttraumatic cognitions about the self appear to be an important factor in the manifestation of SI among veterans with PTSD and should be monitored as a potential indicator of suicide risk.     

VA community-based outpatient clinics: performance measures based on patient perceptions of care

BACKGROUND: The Department of Veterans Affairs (VA) recently initiated a system of Community- Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to determine the effect of CBOCs on patients' perceptions of care. RESEARCH DESIGN: The study design is a cross-sectional survey. SUBJECTS: This study compares 4,980 patients from 44 geographically diverse CBOCs to 4,159 patients from 36 parent VA Medical Center primary care clinics administratively and geographically associated with the CBOCs studied. MEASURES: Survey data were obtained from the 1998 VA National Outpatient Customer Satisfaction Survey which assesses eight multiitem scales addressing access and timeliness of care, education/information, patient preferences, emotional support, coordination of care, courtesy, and specialty care access. Each scale was evaluated based upon item responses that indicate a problem with care. The survey also contained SF-12 health status measures used for case-mix adjustment. RESULTS: Multivariate logistic regression controlling for patient health status measures revealed that CBOC patients reported fewer problems with care than VA-based patients on 7 of 8 scales though the absolute differences were small for most of the scales. The largest difference was observed for the access/timeliness scale. Significant differences between VA-staff and contract CBOCs were not observed. CONCLUSIONS: These results suggest that veterans participating in VA's initiative to provide primary care in community-based settings report no more than, and in some dimensions fewer problems with care compared with veterans who receive care in VAMC clinics.     

Prevalence and characteristics of driving difficulties in Operation Iraqi Freedom/Operation Enduring Freedom combat returnees

We studied the prevalence and characteristics of self-reported driving difficulties and examined their association with traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans who were seen at a Department of Veterans Affairs outpatient polytrauma clinic. In this study, we used a brief driving questionnaire and chart reviews to assess the prevalence and characteristics of driving difficulties in the following four groups of patients: TBI only, PTSD only, TBI + PTSD, and Neither (neither TBI nor PTSD). Compared with before deployment, 93% of OIF/OEF veterans seen in the polytrauma clinic reported more difficulties with driving in at least one domain, with the most common areas of difficulty being (1) problems with anger or impatience (82%), (2) general driving difficulties (65%), and (3) experiences with near misses (57%). Patients with PTSD (with or without TBI) reported the most significant driving impairments, whereas respondents with a history of only TBI endorsed driving difficulties similar to veterans without either diagnosis. Qualitative analysis of veterans' comments also revealed similar patterns. Self-reported driving problems were common among OIF/OEF returnees. Respondents who had a diagnosis of PTSD (with or without TBI) reported the most severe driving difficulties since returning from deployment. The association between PTSD and driving problems warrants further investigation.     

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.     

The reality of virtual learning for nurses in the largest integrated health care system in the nation

The health care network and hospital system within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), provides employment to more than 56,000 nursing personnel and serves as clinical education site to countless other nursing and health professional students. Nurse administrators and educators are posed with the challenge of providing an environment in which each nurse is able to gain needed knowledge, learn new skills, and share and communicate this knowledge with other colleagues. The education of nurses improves the health status of veterans while also realizing individual professional enhancement. Regional and cultural diversity of the system present challenges to education, in both delivery and content. VHA's learning organizations, the Employee Education System and the Office of Special Projects, have maximized new technologies and information systems to provide innovative, virtual education opportunities, capitalizing on the benefits of informal and formal learning, thus moving VHA to the forefront in knowledge sharing and dissemination. The Virtual Learning Center, VA Knowledge Network, Learning Catalog, and VA Learning Online provide VHA's nurses with interactive, desktop virtual learning opportunities.