Gender Differences in Health Care Utilization Among Veterans with Chronic Pain

Background Previous research reports that 48% of veterans regularly experience and express concern over pain. Outpatient service use is higher for veterans with pain than for veterans without pain. Our study objective was to identify differences in outpatient utilization between men and women veterans with chronic pain. Methods We identified all men and women veterans at the Durham Veterans Affairs Medical Center in fiscal year (FY) 2002 between the ages of 21 and 60 that had two visits for the same pain location at least 6 weeks apart as determined by ICD-9 coding. Men and women were age-matched at a 2:1 ratio. We then compared the number of outpatient visits between genders in FY 2003. Results We identified 406 female and 812 male veterans. The mean number of clinic visits for women was 25.2 (SD 30.2) and for men 17.6 (SD 24.1). After adjusting for multiple pain sites, psychiatric diagnoses, age, and comorbidities, women veterans had a 27% higher rate of outpatient visits than men (incidence rate ratio [RR] 1.27, 95% confidence [CI] 1.15 to 1.41). Specifically, women had higher rates of visits to primary care (RR 1.36, 95% CI 1.24 to 1.50), physical therapy (RR 1.67, 95% CI 1.20 to 2.33), and other clinics (RR 1.28, 95% CI 1.14 to 1.44), and had a higher rate of visits to address pain (RR 1.15, 95% CI 1.02 to 1.30) than men. Conclusions This is the first study to examine gender differences in chronic pain and utilization in the veteran population. Women veterans with chronic pain may need more resources to adequately manage chronic pain conditions as well as associated comorbidities and psychiatric disease. Portions of this research were presented at the annual Society of General Internal Medicine conference, May, 2005, as well as the Women’s Health Congress, June, 2005.     

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial

BACKGROUND

Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve.

OBJECTIVE

We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans.

DESIGN

This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans.

PARTICIPANTS

Homeless Veterans not receiving primary care participated in the study.

INTERVENTIONS

An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented.

MAIN MEASURE

We measured receipt of primary care within 4 weeks of study enrollment.

KEY RESULTS

Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6 % were male, 43.0 % were from a minority population, 12.0 % were unsheltered, 25.5 % were staying in a dusk-to-dawn emergency shelter, 26.1 % were in transitional housing, while 27.7 % were in an unstable, doubled-up arrangement. At one month, 77.3 % of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7 % had been seen in primary care. This was followed by the CO-only group, 50.0 % of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0 % and the Usual Care arm at 30.6 %. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care.

CONCLUSIONS

Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.KEY WORDS: homeless persons, patient engagement, community outreach, Veterans     

Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&;D) held a state-of-the-art (SOTA) conference titled “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management” in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans’ access to non-pharmacological approaches.     

Relative Undernourishment and Food Insecurity Associations with Plasmodium falciparum Among Batwa Pygmies in Uganda: Evidence from a Cross-Sectional Survey

Although malnutrition and malaria co-occur among individuals and populations globally, effects of nutritional status on risk for parasitemia and clinical illness remain poorly understood. We investigated associations between Plasmodium falciparum infection, nutrition, and food security in a cross-sectional survey of 365 Batwa pygmies in Kanungu District, Uganda in January of 2013. We identified 4.1% parasite prevalence among individuals over 5 years old. Severe food insecurity was associated with increased risk for positive rapid immunochromatographic test outcome (adjusted relative risk [ARR] = 13.09; 95% confidence interval [95% CI] = 2.23–76.79). High age/sex-adjusted mid-upper arm circumference was associated with decreased risk for positive test among individuals who were not severely food-insecure (ARR = 0.37; 95% CI = 0.19–0.69). Within Batwa pygmy communities, where malnutrition and food insecurity are common, individuals who are particularly undernourished or severely food-insecure may have elevated risk for P. falciparum parasitemia. This finding may motivate integrated control of malaria and malnutrition in low-transmission settings.     

The Association of Abuse and Symptoms Suggestive of Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Results from the Boston Area Community Health Survey

Objective To determine the effect of reported sexual, physical, or emotional abuse on the symptoms suggestive of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and to determine the effect of race/ethnicity on these patterns. Methods The Boston Area Community Health (BACH) survey used a multi-stage stratified cluster sample to randomly sample 5,506 adults aged 30–79 from the city of Boston. BACH recruited 2,301 men (700 Black, 766 Hispanic, and 835 White). Interviewers administered questions approximating the National Institutes of Health chronic prostatitis symptom index (CPSI), and symptoms suggestive of CP/CPPS were measured by the definition of perineal and/or ejaculatory pain and CPSI pain score of 4+. Questions about previous abuse were obtained from a validated self-administered questionnaire during the home visit. Logistic regression was used to determine the effect of abuse on the likelihood of a man having symptoms suggestive of CP/CPPS. Results The prevalence of symptoms suggestive of CP/CPPS was 6.5%. Men who reported having experienced sexual, physical, or emotional abuse had increased odds (1.7–3.3) for symptoms suggestive of CP/CPPS. Previous abuse increased both the pain and urinary scores from the CPSI. Conclusion Symptoms suggestive of CP/CPPS are not uncommon in a community-based population of men. For men presenting with symptoms suggestive of CP/CPPS, clinicians may wish to consider screening for abuse.     

Self-reported Weight Loss Among Adults with Diabetes: Results From a National Health Survey

Although weight reduction can have a favourable effect on glucose control among persons with diabetes mellitus (DM), no national data have been used to describe weight loss among persons with DM. To address this gap, national survey data were used to assess self-reported weight loss among persons from the USA with and without DM and to identify how other factors might interact with DM to increase the risk of weight loss. Data from the 1989 United States National Health Interview Survey were analysed for 2185 persons with DM and 18304 persons without DM. Fifty-five percent of persons with DM reported they were attempting weight loss compared with only 43 % of persons without DM. Among those who attempted weight loss, one-quarter of persons with DM lost at least 15 lb (approximately 5.6 kg) during the prior year compared with only 16 % of persons without DM. After multivariate adjustment for demographic variables, health care utilization, cigarette smoking, and degree of overweight, persons with DM were 1.7 times more likely to have lost 15 lb than were persons without DM. Among persons with DM, having been hospitalised twice and having consulted a dietitian or nutritionist during the prior year were both related to intentional weight loss. Further research is needed to clarify the roles of health status and medical resources in weight loss effort and success.     

Non-Pharmacological Approaches to Pain Management in Residential Aged Care: a Pre-Post-Test Study

Objectives: The project aimed to evaluate a pain management program (PMP) using non-pharmacological approaches at five residential aged care facilities (RACFs) in Australia.

Methods: The PMP involved a physiotherapist implementing four sessions per week of treatments (massage therapy, TENS, exercises and stretching, or combinations of these). Ninety-five participants were recruited (average age, 83 years; SD = 7.6; 38% men, 62% women; 56% with dementia). Sessions lasted approximately 10 minutes, and residents’ levels of pain were recorded using a 5-point scale before and after each treatment. The intervention period for each participant was the first consecutive 8 weeks in which they received the intervention.

Results: Data analyses showed: (1) a small but statistically significant decrease in the number of as required (PRN) medications; and (2) a decrease in average pain ratings from pre-session to post-session from 2.4 (some to moderate pain) to 1.1 (a little pain). Notably, residents with dementia received lower pain ratings than those without.

Conclusions: Non-pharmacological approaches to pain in residential care settings are effective, especially when two or more are combined. Staff working in residential care settings should rely on best practice to recognise pain in residents with dementia.

Clinical Implications: Non-pharmacological interventions may be effective in reducing pain and reliance on PRN medications in residential care settings, especially when two or more are used. Staff working in residential aged care settings should be provided with training in pain assessment and management, with particular attention to residents with dementia.     

Information on Cardiovascular Disease in the Digital Era: Results From a Cross-Sectional Patient Survey

Public health strategies to reduce cardiovascular disease (CVD) rely on the effective dissemination of evidence-based information to at-risk populations. An improved understanding of the information sources patients use can facilitate content development and promote awareness of effective interventions for CVD prevention, monitoring, and management. We therefore sought to determine the contemporary patterns of CVD information source usage via a prospective, cross-sectional survey study of CVD information sources in a primary care centre in Ontario, Canada. Primary source(s) used for CVD information were defined as: traditional media (television or print media), Internet-based sources, or community resources (community agencies and health care providers). Of 4682 consecutively screened patients aged > 18 years 3189 (68%) participated in the survey. The mean age of the survey respondents was 37 ± 14 years and 54.4% were female. Traditional media (71%) were used more frequently than Internet-based sources (45%) or community health services (23%). Only 20% of respondents identified health care providers as the source of information for CVD. Compared with respondents aged ≥ 55 years, the adjusted odds of Internet-based source use were significantly higher among younger age groups, whereas the adjusted odds of print media and health services usage was lowest among ages 25-34 years. Although traditional print and electronic media remain the primary resource for CVD-related information, younger individuals increasingly rely on Internet-based sources. These findings have important implications for public health policy and resource allocation, highlighting the importance of maintaining traditional media presence in addition to the development of high-quality Internet-based sources of CVD information.     

A Look at Person-Centered and Family-Centered Care Among Older Adults: Results from a National Survey

BACKGROUNDPerson-centered and family-centered care represents the pinnacle of health care quality, but delivering it is challenging, as is assessing whether it has occurred. Prior studies portray older adults as passive in health decisions and burdened by care—but emphasize age-based differences or focus on vulnerable subgroups.OBJECTIVESWe aimed to examine domains of person-centered and family-centered care among older adults and whether the social context in which older adults manage their health relates to preferences for participating in health decisions and experiences with care.CONCLUSIONSAttaining person-centered and family-centered care will require strategies that respect diverse decision-making preferences, minimize treatment burden, and support the broader social context in which older adults manage their health.KEY WORDS: decision-making, treatment burden, self-management, patient-centered care, older adultsPerson-centered and family-centered care is thought to represent the pinnacle of health care quality.¹ However, delivering it is challenging, as is our ability to assess whether it has occurred.² Attaining person-centered and family-centered care is particularly important and challenging in the care of older persons, given vast heterogeneity in health and function, treatment preferences, and individual goals.^3,4 Because many older adults are heavy users of health services, they are more susceptible to treatment burden as well as harms associated with complicated therapeutic and preventive regimens.^5–7 Age-related changes in sensory, cognitive, and physical function may prompt some older adults to rely on or choose to involve family members or close friends in managing their health.^8,9The existing literature generally indicates that older adults prefer a passive role in health care decision-making^10–12 and portrays older adults as burdened by care.^13,14 However, prior studies have typically emphasized age-related differences,^10,11 or focused on targeted subgroups of older adults with low-literacy, poor health, or specific conditions.^12–16 Understanding what people view to be important and their experience of care is foundational in the measurement of person-centered and family-centered care.² Therefore, we designed a study to understand older adults’ preferences for participating in health care decision-making and their experiences with care as measured by aspects of treatment burden associated with managing health. We address existing gaps in the measurement of person-centered and family-centered care by drawing on a nationally representative, population-based data source to examine issues that are meaningful to those receiving care, focusing on the entire care experience as opposed to a single decision or point in time.² We sought to understand if older adults’ perspectives vary with respect to whether they manage their health independently or with the involvement of family or close friends.     

Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans

BACKGROUND

While prior research characterizes women Veterans’ barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.

OBJECTIVES

To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.

DESIGN

Cross-sectional, population-based 2008–2009 national telephone survey.

PARTICIPANTS

Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.

MAIN MEASURES

Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.

KEY RESULTS

Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p?=?0.007), higher income (p?<?0.001), and were more likely to have health insurance (p?<?0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p?<?0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.

CONCLUSIONS

We found high VA attrition despite recent advances in VA care for women Veterans. Women’s attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.

     

Meeting the Treatment Needs of Veterans with Substance Use Disorders

Substance use disorder (SUD) treatment staff from the Brooklyn Veterans Administration Hospital and Samaritan Village describe current practices and challenges in treating the increasing Veteran population with SUD. Article addresses best practices for treating Veterans with SUDs, posttraumatic stress disorder, and traumatic brain injury complications; military sexual trauma; combat versus noncombat status; significance of period served (WW II, Korea, Vietnam, Kuwait/Iraq I, Iraq II, Afghanistan); active service obligations; treatment interventions for trauma survivors; gender treatment differences; medically assisted treatments, especially for those with pain issues; family involvement; benefit seeking; self-help Step 1’s “surrender” and “powerlessness” terms; access to treatment issues; returning home adjustment; and coordinating interdisciplinary treatment services.     

Chronic Pain and Obesity in Elderly People: Results from the Einstein Aging Study

OBJECTIVES: To determine the prevalence of chronic pain in elderly people and its relationship with obesity and associated comorbidities and risk factors.
DESIGN: Cross-sectional.
SETTING: Community.
PARTICIPANTS: A representative community sample of 840 subjects aged 70 and older.
MEASUREMENTS: The prevalence of chronic pain and its relationship with obesity (categories defined according to body mass index (BMI)), other medical risk factors, and psychiatric comorbidities were examined. Chronic pain was defined as pain of at least moderate severity (≥4 on a 10-point scale) some, most, or all of the time for the previous 3 months.
RESULTS: The sample was mostly female (62.8%), and the average age was 80 (range 70–101). The prevalence of chronic pain was 52% (39.7% in men; 58.9% in women). Subjects with chronic pain were more likely to report a diagnosis of depression (odds ratio (OR)=2.5, 95% confidence interval (CI)=1.40–4.55) and anxiety (OR=2.3, 95% CI=1.22–4.64). Obese subjects (BMI 30–34.9) were twice as likely (OR=2.1, 95%CI=1.33–3.28) and severely obese subjects (BMI≥35) were more than four times as likely (OR=4.5, 95% CI=1.85–12.63) as those of normal weight (BMI 18.5–24.9) to have chronic pain. Obese subjects were significantly more likely to have chronic pain in the head, neck or shoulder, back, legs or feet, and abdomen or pelvis than subjects who were not obese. In multivariate models, obesity (OR=2.0, 95% CI=1.27–3.26) and severe obesity (OR=4.1, 95% CI=1.57–10.82) were associated with chronic pain after adjusting for age, sex, diabetes mellitus, hypertension, depression, anxiety, and education.
CONCLUSION: Chronic pain is common in this elderly population, affects women more than men, and is highly associated with obesity.