Gender Differences Among Veterans Deployed in Support of the Wars in Afghanistan and Iraq

BACKGROUND

The changing scope of women’s roles in combat operations has led to growing interest in women’s deployment experiences and post-deployment adjustment.

OBJECTIVES

To quantify the gender-specific frequency of deployment stressors, including sexual and non-sexual harassment, lack of social support and combat exposure. To quantify gender-specific post-deployment mental health conditions and associations between deployment stressors and posttraumatic stress disorder (PTSD), to inform the care of Veterans returning from the current conflicts.

DESIGN

National mail survey of OEF/OIF Veterans randomly sampled within gender, with women oversampled.

SETTING

The community.

PARTICIPANTS

In total, 1,207 female and 1,137 male Veterans from a roster of all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. Response rate was 48.6 %.

MAIN MEASURES

Deployment stressors (including combat and harassment stress), PTSD, depression, anxiety and alcohol use, all measured via self-report.

KEY RESULTS

Women were more likely to report sexual harassment (OR?=?8.7, 95% CI: 6.9, 11) but less likely to report combat (OR?= 0?.62, 95 % CI: 0.50, 0.76). Women and men were equally likely to report symptoms consistent with probable PTSD (OR = 0?.87, 95 % CI: 0.70, 1.1) and symptomatic anxiety (OR ?= ?1.1, 9 5% CI: 0.86, 1.3). Women were more likely to report probable depression (OR?=?1.3, 95 % CI: 1.1, 1.6) and less likely to report problematic alcohol use (OR ?= 0?.59, 9 5% CI: 0.47, 0.72). With a five-point change in harassment stress, adjusted odds ratios for PTSD were 1.36 (95 % CI: 1.23, 1.52) for women and 1.38 (95 % CI: 1.19, 1.61) for men. The analogous associations between combat stress and PTSD were 1.31 (95 % CI: 1.24, 1.39) and 1.31 (95 % CI: 1.26, 1.36), respectively.

CONCLUSIONS

Although there are important gender differences in deployment stressors—including women’s increased risk of interpersonal stressors—and post-deployment adjustment, there are also significant similarities. The post-deployment adjustment of our nation’s growing population of female Veterans seems comparable to that of our nation’s male Veterans.

     

Different polysomnographic patterns in military veterans with obstructive sleep apnea in those with and without post-traumatic stress disorder

Introduction and objectives

Obstructive sleep apnea (OSA) is a prevalent disorder among military veterans. The goal of this study is to compare the polysomnographic patterns of OSA in military veterans who have a history of post-traumatic stress disorder (PTSD) with those of veterans who have not PTSD.

Materials and methods

Seventy-two Iranian military male veterans were classified into two groups: those with PTSD (40 cases) and those without PTSD (32 cases). Each participant was diagnosed with OSA using an overnight polysomnography, during which sleep-related parameters such as sleep efficiency (SE) and apnea-related events were detected. The body mass index (BMI) and Epworth Sleepiness Scale (ESS) were also assessed.

Results

For the PTSD group, mean age was 53.83?±?7.3 years, elapsed time since they participated in war was 28.3?±?3.4 years, apnea-hypopnea index (AHI) was 41.2?±?27, SE was 77.7?±?17.55%, ESS was 7.93?±?2.04, BMI was 26.5?±?5.7, and PLM index was 12.725?±?8.64. The above respective parameters for the non-PTSD group were 51.33?±?5.9 years, 28.3?±?3.4 years, 30.33?±?14.7, 82.4?±?15.65%, 10.08?±?3.02, 31.5?±?6.7, and 8.8?±?3.54. The relationships of AHI with ESS and BMI were not significant in PTSD group.

Conclusion

OSA in military veterans suffering from PTSD presents more often with insomnia than obesity or increased daytime sleepiness. These findings are different from those typically seen in non-PTSD veterans with OSA.

     

Sexual Victimization,Health Status,and VA Healthcare Utilization Among Lesbian and Bisexual OEF/OIF Veterans

Background

Many lesbian and bisexual (LB) women veterans may have been targets of victimization in the military based on their gender and presumed sexual orientation, and yet little is known regarding the health or mental health of LB veterans, nor the degree to which they feel comfortable receiving care in the VA.

Objective

The purpose of this study was to examine the prevalence of mental health and gender-specific conditions, VA healthcare satisfaction and trauma exposure among LB veterans receiving VA care compared with heterosexually-identified women veterans receiving.

Design

Prospective cohort study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans at two large VA facilities.

Participants

Three hundred and sixty five women veterans that completed a baseline survey. Thirty-five veterans (9.6 %) identified as gay or lesbian (4.7 %), or bisexual (4.9 %).

Main Measures

Measures included sexual orientation, military sexual trauma, mental and gender-specific health diagnoses, and VA healthcare utilization and satisfaction.

Key Results

LB OEF/OIF veterans were significantly more likely to have experienced both military and childhood sexual trauma than heterosexual women (MST: 31 % vs. 13 %, p?<?.001; childhood sexual trauma: 60 % vs. 36 %, p?=?.01), to be hazardous drinkers (32 % vs. 16 %, p?=?.03) and rate their current mental health as worse than before deployment (35 % vs. 16 %, p?<?.001).

Conclusions

Many LB veterans have experienced sexual victimization, both within the military and as children, and struggle with substance abuse and poor mental health. Health care providers working with female Veterans should be aware of high rates of military sexual trauma and childhood abuse and refer women to appropriate VA treatment and support groups for sequelae of these experiences. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.

     

Patients with celiac disease may have normal weight or may even be overweight

Background

It is believed that patients with celiac disease (CeD) are likely to be underweight. Data from west suggest that 8 % to 40 % of them can be overweight or obese. We reviewed data on body mass index (BMI) of our patients with CeD and derived the correlations between BMI and other disease characteristics.

Methods

We retrospectively studied case records of 210 adolescent and adult patients with CeD at the Celiac Disease Clinic. We classified BMI as underweight, normal weight, overweight, and obese based on the Consensus Statement for Diagnosis of Obesity, Abdominal Obesity and the Metabolic Syndrome for Asian Indians for those with age >18 years and revised Indian Association of Pediatrics BMI-for-age charts for those between 12 and 18 years.

Results

Of 210 patients, 76 (36.2 %) were underweight, 115 (54.8 %) were normal weight, 13 (6.2 %) were overweight, and 6 (2.9 %) were obese. There was no difference in the proportion of underweight between male and female patients with CeD. The mean age of underweight patients was similar to those having normal or overweight. There was no difference in the mean duration of symptoms; frequencies of diarrhea, anorexia, and weakness; anemia; titer of anti-tissue transglutaminase antibody; and severity of villous atrophy in those with underweight or normal weight or overweight.

Conclusions

In our practice, only one third of patients with CeD had low BMI. A diagnosis of CeD should not be excluded if patient has normal or high BMI.

     

Collaborating Across the Departments of Veterans Affairs and Defense to Integrate Mental Health and Chaplaincy Services

BACKGROUND

Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains’ current and potential roles in caring for veterans and service members with mental health needs.

OBJECTIVE

Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings.

DESIGN

A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains.

PARTICIPANTS

Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n?=?2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities.

MAIN MEASURES

Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete.

KEY RESULTS

When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8–100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved.

CONCLUSIONS

Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

     

A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial

Background

A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity.

Objective

To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone.

Design

Two-arm randomized trial at three sites.

Setting

Primary care clinics at Veterans Affairs facilities.

Participants

Four hundred seventeen veterans with at least one modifiable risk factor (BMI?≥?30, <?150 min of at least moderate physically activity per week, or current smoker).

Intervention

Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors.

Measurements

Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS).

Results

Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥?30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR?=?2.5; 95% CI: 1.7, 3.9; p?<?0.0001), higher rates of program participation, 40 vs 23% (OR?=?2.3; 95% CI: 1.5, 3.6; p?=?0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p?=?0.03), but no change in FRS scores, mean difference 0.7 (95% CI ??0.7, 2.2; p?=?0.33).

Conclusions

Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors.

ClinicalTrials.gov Identifier

NCT01828567

     

Predictors of Hypertension Awareness,Treatment, and Control Among Mexican American Women and Men

BACKGROUND

The burden of hypertension and related health care needs among Mexican Americans will likely increase substantially in the near future.

OBJECTIVES

In a nationally representative sample of U.S. Mexican American adults we examined: 1) the full range of blood pressure categories, from normal to severe; 2) predictors of hypertension awareness, treatment and control and; 3) prevalence of comorbidities among those with hypertension.

DESIGN

Cross-sectional analysis of pooled data from the National Health and Nutrition Examination Surveys (NHANES), 1999–2004.

PARTICIPANTS

The group of participants encompassed 1,359 Mexican American women and 1,421 Mexican American men, aged 25–84 years, who underwent a standardized physical examination.

MEASUREMENTS

Physiologic measures of blood pressure, body mass index, and diabetes. Questionnaire assessment of blood pressure awareness and treatment.

RESULTS

Prevalence of Stage 1 hypertension was low and similar between women and men (～10%). Among hypertensives, awareness and treatment were suboptimal, particularly among younger adults (65% unaware, 71% untreated) and those without health insurance (51% unaware, 62% untreated). Among treated hypertensives, control was suboptimal for 56%; of these, 23% had stage ≥2 hypertension. Clustering of CVD risk factors was common; among hypertensive adults, 51% of women and 55% of men were also overweight or obese; 24% of women and 23% of men had all three chronic conditions-hypertension, overweight/obesity and diabetes.

CONCLUSION

Management of hypertension in Mexican American adults fails at multiple critical points along an optimal treatment pathway. Tailored strategies to improve hypertension awareness, treatment and control rates must be a public health priority.

     

Access to Mental Health Treatment by English Language Proficiency and Race/Ethnicity

Background

Limited English proficiency (LEP) may contribute to mental health care disparities, yet empirical data are limited.

Objective

To quantify the language barriers to mental health care by race/ethnicity using a direct measure of LEP is the objective of the study.

Design

Cross-sectional analysis of the 2001 California Health Interview Survey is the study’s design.

Participants

Adults aged 18 to 64 who provided language data (n?=?41,984) were the participants of the study.

Measurement

Participants were categorized into three groups by self-reported English proficiency and language spoken at home: (1) English-speaking only, (2) Bilingual, and (3) Non-English speaking. Mental health treatment was measured by self-reported use of mental health services by those reporting a mental health need.

Results

Non-English speaking individuals had lower odds of receiving needed services (OR: 0.28; 95% CI: 0.17–0.48) than those who only spoke English, when other factors were controlled. The relationship was even more dramatic within racial/ethnic groups: non-English speaking Asian/PIs (OR?=?0.15; 95% CI: 0.30–0.81) and non-English speaking Latinos (OR: 0.19; 95% CI: 0.09–0.39) had significantly lower odds of receiving services compared to Asian/PIs and Latinos who spoke only English.

Conclusions

LEP is associated with lower use of mental health care. Since LEP is concentrated among Asian/PIs and Latinos, it appears to contribute to racial/ethnic disparities in mental health care. Heightened attention to LEP is warranted in both mental health practice and policy.

     

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

Objectives

To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes?

Data Sources

OVID MEDLINE, CINAHL, PsychINFO.

Study Eligibility Criteria, Participants, and Interventions

English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included.

Appraisal and Synthesis Methods

Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes.

Results

Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n?=?5 articles), use of Telemedicine (n?=?5 articles), and Primary Care Mental Health Integration (n?=?6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences.

Limitations

Included studies were largely of poor to fair methodological quality.

Conclusions and Implications of Key Findings

Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.

     

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common.

OBJECTIVE

The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure.

DESIGN

We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5.

PARTICIPANTS

A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White.

MEASURES

The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences.

KEY RESULTS

The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC?=?0.941; 95 % C.I.: 0.912– 0.969). Whereas a cut score of 3 maximized sensitivity (κ[1]) = 0.93; SE?=?.041; 95 % C.I.: 0.849–1.00), a cut score of 4 maximized efficiency (κ[0.5] = 0.63; SE?= 0.052; 95 % C.I.: 0.527–0.731), and a cut score of 5 maximized specificity (κ[0] = 0.70; SE?=?0.077; 95 % C.I.: 0.550–0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report.

CONCLUSIONS

The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.

     

Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare

Background

Distance to healthcare services is a known barrier to access. However, the degree to which distance is a barrier is not well described. Distance may impact different patients in different ways and be mediated by the context of medical need.

Objective

Identify factors related to distance that impede access to care for rural veterans.

Approach

Mixed-methods approach including surveys, in-depth interviews, and focus groups at 15 Veterans Health Administration (VHA) primary care clinics in 8 Midwestern states. Survey data were compiled and interviews transcribed and coded for thematic content.

Participants

Surveys were completed by 96 patients and 88 providers/staff. In-depth interviews were completed by 42 patients and 64 providers/staff. A total of 7 focus groups were convened consisting of providers and staff.

Key results

Distance was identified by patients, providers, and staff as the most important barrier for rural veterans seeking healthcare. In-depth interviews revealed specific examples of barriers to care such as long travel for common diagnostic services, routine specialty care, and emergency services. Patient factors compounding the impact of these barriers were health status, functional impairment, travel cost, and work or family obligations. Providers and staff reported challenges to healthcare delivery due to distance.

Conclusions

Distance as a barrier to healthcare was not uniformly defined. Rather, its importance was relative to the health status and resources of patients, complexity of service provided, and urgency of service needed. Improved transportation, flexible fee-based services, more structured communication mechanisms, and integration with community resources will improve access to care and overall health status for rural veterans.

     

Dual Medicare and Veteran Health Administration Use and Ambulatory Care Sensitive Hospitalizations

OBJECTIVE

The objective of the study is to examine the association between ambulatory care sensitive hospitalizations (ACSH) and dual Medicare/Veteran Health Administration use.

PARTICIPANTS

A nationally representative sample of Medicare beneficiaries, who participated in the Medicare Current Beneficiary Survey (MCBS).

DESIGN/MEASUREMENTS

Cross-sectional analyses (

RESULTS

Among inpatient users, 10.1% had ACSH events for acute conditions and 15.8% for chronic conditions. Among all survey respondents, 5% had any ACSH event. Among predominant-VHA users the rate was 4.9% and among veterans with some VHA use it was 3.7%. In bivariate and multivariate analyses, dual Medicare/VHA use was not significantly associated with any ACSH.

CONCLUSION

In a representative sample of Medicare beneficiaries, despite low income and health status, veterans with dual Medicare/VHA use were as likely as veterans without dual use to have any ACSH, perhaps due to expanded healthcare access and emphasis on primary care in the VHA system.

     

Weight Management in Patients with Type 2 Diabetes: a Multidisciplinary Real-world Approach

Purpose of Review

Obesity and type 2 diabetes (T2D) are closely linked metabolic diseases. Most individuals with T2D are overweight or obese, which raises their cardiovascular risk. The etiology of both diseases is multifaceted, thus requiring a multidisciplinary approach to control them. This review describes the most effective multidisciplinary approach to weight management in patients with T2D in real-world clinical practice.

Recent Findings

Weight management programs in real-world clinical settings lead to long-term weight loss for up to 5 years.

Summary

Multidisciplinary approach to manage obesity and T2D through weight reduction is feasible in real-world clinical practice and is recommended as part of the treatment plan for patients with T2D who are overweight or obese. Recent data demonstrates that multidisciplinary approach to weight management in patients with T2D results in long-term weight loss and is associated with improved cardiovascular risk factors.

     

Cardiovascular Disease Risk Factors Among Women Veterans at VA Medical Facilities

BACKGROUND

Hypertension, hyperlipidemia, diabetes, and obesity in middle adulthood each elevate the long-term risk of cardiovascular disease (CVD). The prevalence of these conditions among women veterans is incompletely described.

OBJECTIVE

To describe the prevalence of CVD risk factors among women veterans in middle adulthood.

DESIGN

Serial cross-sectional studies of data from the Diabetes Epidemiologic Cohorts (DEpiC), a national, longitudinal data set including information on all patients in the Veterans Health Administration (VA).

PARTICIPANTS

Women veterans (n?=?255,891) and men veterans (n?=?2,271,605) aged 35–64 receiving VA care in fiscal year (FY) 2010.

MAIN MEASURES

Prevalence of CVD risk factors in FY2010 by age and, for those aged 45–54 years, by race, region, period of military service, priority status, and mental illness or substance abuse; prevalence by year from 2000 to 2010 in women veterans receiving VA care in both 2000 and 2010 who were free of the factor in 2000.

KEY RESULTS

Hypertension, hyperlipidemia, and diabetes were common among women and men, although more so among men. Hypertension was present in 13 % of women aged 35–44 years, 28 % of women aged 45–54, and 42 % of women aged 55–64. Hyperlipidemia prevalence was similar. Diabetes affected 4 % of women aged 35–44, and increased more than four-fold in prevalence to 18 % by age 55–64. The prevalence of obesity increased from 14 % to 18 % with age among women and was similarly prevalent in men. The relative rate of having two or more CVD risk factors in women compared to men increased progressively with age, from 0.55 (35–44 years) to 0.71 (45–54) to 0.73 (55–64). Most of the women with a factor present in 2010 were first diagnosed with the condition in the 10 years between 2000 and 2010.

CONCLUSIONS

CVD risk factors are common among women veterans aged 35–64. Future research should investigate which interventions would most effectively reduce risk in this population.

     

Military Sexual Trauma Among Homeless Veterans

BACKGROUND

Military sexual trauma (MST) is the Veteran Health Administration’s (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.

OBJECTIVE

To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.

DESIGN AND PARTICIPANTS

National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.

MAIN MEASURES

All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.

KEY RESULTS

Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.

CONCLUSIONS

A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.

     

Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy

Background

Expert guidelines recommend non-pharmacologic treatments and non-opioid medications for chronic pain and recommend against initiating long-term opioid therapy (LTOT).

Objective

We examined whether veterans with incident chronic pain receiving care at facilities with greater utilization of non-pharmacologic treatments and non-opioid medications are less likely to initiate LTOT.

Design

Retrospective cohort study

Participants

Veterans receiving primary care from a Veterans Health Administration facility with incident chronic pain between 1/1/2010 and 12/31/2015 based on either of 2 criteria: (1) persistent moderate-to-severe patient-reported pain and (2) diagnoses “likely to represent” chronic pain.

Main measures

The independent variable was facility-level utilization of pain-related treatment modalities (non-pharmacologic, non-opioid medications, LTOT) in the prior calendar year. The dependent variable was patient-level initiation of LTOT (≥?90 days within 365 days) in the subsequent year, adjusting for patient characteristics.

Key results

Among 1,094,569 veterans with incident chronic pain from 2010 to 2015, there was wide facility-level variation in utilization of 10 pain-related treatment modalities, including initiation of LTOT (median, 16%; range, 5–32%). Veterans receiving care at facilities with greater utilization of non-pharmacologic treatments were less likely to initiate LTOT in the year following incident chronic pain. Conversely, veterans receiving care at facilities with greater non-opioid and opioid medication utilization were more likely to initiate LTOT; this association was strongest for past year facility-level LTOT initiation (adjusted rate ratio, 2.10; 95% confidence interval, 2.06–2.15, top vs. bottom quartile of facility-level LTOT initiation in prior calendar year).

Conclusions

Facility-level utilization patterns of non-pharmacologic, non-opioid, and opioid treatments for chronic pain are associated with subsequent patient-level initiation of LTOT among veterans with incident chronic pain. Further studies should seek to understand facility-level variation in chronic pain care and to identify facility-level utilization patterns that are associated with improved patient outcomes.

     

Access to Care for Women Veterans: Delayed Healthcare and Unmet Need

BACKGROUND

Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans’ experience.

OBJECTIVE

We examined the association of general and veteran-specific barriers on access to healthcare among women veterans.

DESIGN AND PARTICIPANTS

Cross-sectional, population-based national telephone survey of 3,611 women veterans.

MAIN MEASURE

Delayed healthcare or unmet healthcare need in the prior 12 months.

KEY RESULTS

Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18–34, 35–49, 50–64, and 65-plus age groups;

CONCLUSIONS

Both general and veteran-specific factors impact women veterans’ access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans’ knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.