Older veterans' future use of VA health care services

This study is a secondary analysis of the Harris Survey of Aging Veterans (SAV) and is designed to identify variables that may be associated with older veterans' future use of the Veterans Administration (VA) health care system. Using regression and discriminant analysis techniques, the study identifies variables that may predispose older veterans to use the VA health care system in the next 10 years. The results indicate that older veterans may elect to use their health care benefits on objective criteria consistent with their health and financial resources, e.g., past use of veterans benefits, expected health status, and private insurance coverage. These variables suggest that the VA's recently enacted means test and the removal of automatic age eligibility will disenfranchise few older veterans.     

Gender disparities in Veterans Health Administration care: importance of accounting for veteran status

BACKGROUND: In an effort to assess and reduce gender-related quality gaps, the Veterans Health Administration (VHA) has promoted gender-based research. Historically, such appraisals have often relied on secondary databases, with little attention to methodological implications of the fact that VHA provides care to some nonveteran patients. OBJECTIVES: To determine whether conclusions about gender differences in utilization and cost of VHA care change after accounting for veteran status. DESIGN: Cross-sectional. SUBJECTS: All users of VHA in 2002 (N = 4,429,414). MEASURES: Veteran status, outpatient/inpatient utilization and cost, from centralized 2002 administrative files. RESULTS: Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men. Among all users, outpatient and inpatient utilization and cost were far lower in women than in men, but in the veteran subgroup these differences decreased substantially or, in the case of use and cost of outpatient care, reversed. Utilization and cost were very low among women employees; women spouses of fully disabled veterans had utilization and costs similar to those of women veterans. CONCLUSIONS: By gender, nonveterans represent a higher proportion of women than of men in VHA, and some large nonveteran groups have low utilization and costs; therefore, conclusions about gender disparities change substantially when veteran status is taken into account. Researchers seeking to characterize gender disparities in VHA care should address this methodological issue, to minimize risk of underestimating health care needs of women veterans and other women eligible for primary care services.     

Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus

BACKGROUND AND OBJECTIVES: Associations of insurance coverage and source of care with use of human immunodeficiency virus (HIV)-related health, mental health, and substance abuse services are examined in a large, diverse, highly active antiretroviral therapy-era cohort. METHODS: Adults who were infected with HIV (n = 3818) were interviewed in clinics and community agencies in Los Angeles, Milwaukee, New York, and San Francisco regarding drug use behaviors, health status, and health care utilization. RESULTS: Most participants were insured by Medicaid. During the previous 3 months, 90% of privately insured, 87% of publicly insured, and 78% of uninsured participants had visited any provider. Publicly and privately insured participants were similar in receipt of antiretrovirals, prophylaxis against Pneumocystis carinii pneumonia, substance abuse services, and antidepressants. Uninsured participants were less likely to receive antiretrovirals but were more likely to use substance abuse services. Participants with no usual source of care were less likely to receive PCP prophylaxis. CONCLUSIONS: A lack of insurance is associated with barriers to care, but the advantage of private over public coverage appears smaller than in previous studies. PCP prophylaxis, substance abuse treatment, and antidepressants remain markedly underutilized. Educational initiatives about these treatments targeting providers and patients are indicated.     

Uninsured but eligible children: are their parents insured? Recent findings from Oregon

BACKGROUND: Despite expansions in public health insurance programs, millions of US children lack coverage. Nearly two-thirds of Oregon's uninsured children seem to be eligible for public insurance. OBJECTIVES: We sought to identify uninsured but eligible children and to examine how parental coverage affects children's insurance status. METHODS: We collected primary data from families enrolled in Oregon's food stamp program, which has similar eligibility requirements to public health insurance in Oregon. In this cross-sectional, multivariable analysis, results from 2861 surveys were weighted back to a population of 84,087 with nonresponse adjustment. Key predictor variables were parental insurance status and type of insurance; the outcome variable was children's insurance status. RESULTS: Nearly 11% of children, presumed eligible for public insurance, were uninsured. Uninsurance among children was associated with being Hispanic, having an employed parent, and higher household earnings (133-185% of the federal poverty level). Children with an uninsured parent were more likely to be uninsured, compared with those who had insured parents (adjusted odds ratio 14.21, 95% confidence interval 9.23-20.34). More surprisingly, there was a higher rate of uninsured children among privately-insured parents, compared with parents covered by public insurance (adjusted odds ratio 4.39, 95% confidence interval 2.00-9.66). CONCLUSIONS: Low-income Oregon parents at the higher end of the public insurance income threshold and those with private insurance were having the most difficulty keeping their children insured. These findings suggest that when parents succeed in pulling themselves out of poverty and gaining employment with private health insurance coverage, children may be getting left behind.     

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.     

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.     

Female veterans' use of health care services

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

Uninsured maternity clients: a concern for quality.

Differences among demographic characteristics, health status indicators, and resource use of maternity clients privately insured, insured through public entitlement funds, or uninsured were examined in a public hospital. The uninsured were in their early twenties, black (44%), single (52%), lived in the central city area, employed in service occupations without health care benefits, and either sought prenatal care later in the pregnancy or not at all. Compared with the privately insured, the uninsured had more lifestyle risks. The uninsured women had a shorter hospital stay with more maternal complications. Insurance coverage and prenatal care were positive predictors of birth weight and lifestyle risk factors detracted. Length of stay was not influenced by insurance coverage but rather by health problems before delivery. Earlier discharge of the uninsured patients suggest the need for quality of care monitoring and outreach programs.     

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

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

Rural Veterans’ Utilization of Non‒Veterans Administration Community Health Care Services

Rural veterans are obtaining non‒Veterans Administration health care at an increasing rate, but information on what community services are accessed is lacking. A secondary analysis of surveys obtained from 6 previous studies conducted in acute care areas was scrutinized for military history and utilization patterns. Depending on age, multiple health care agencies were used. Acute care was relied upon frequently, most often due to pain. The Veterans Administration was infrequently visited. Clinician electronic documentation of military history, inquiry into use of other health care services, and involvement in research to monitor outcomes are suggested to facilitate identification of health needs specific to this population.     

How does lack of insurance affect use of intensive care? A population-based study

OBJECTIVE: One in six Americans aged <65 yrs are without health insurance. Although lack of insurance is associated with reduced access to many health services, the relationship between lack of insurance and use of intensive care services is unclear. We sought to compare the use of intensive care by insured and uninsured populations. DESIGN: Retrospective population-based cross-sectional study of five U.S. states (Florida, Massachusetts, New Jersey, New York, and Virginia), analyzing use of hospital and intensive care unit (ICU) services by all residents of these states <65 yrs of age. Data sources included the five 1999 state hospital discharge databases and the 2000 U.S. Census Bureau Current Population Survey. SETTING: Nonfederal hospitals in the five states (all hospitalizations in these during 1999). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 39.3 million and 7.8 million individuals aged 0-64 yrs with and without insurance, respectively, in the five-state sample. The uninsured population was far less likely to be hospitalized (odds ratio [OR], 0.458; 95% confidence interval [CI], 0.456-0.460; p < .001) and to be admitted to the ICU (OR, 0.581, 95% CI: 0.576-0.587, p < .001). Differences persisted irrespective of age, gender, ethnicity, or reason for admission. Among those hospitalized, the uninsured were more likely to receive intensive care (OR, 1.24; 95% CI, 1.22-1.25; p < .01). Hospital mortality rates for patients admitted to the ICU ranged by age from 4.0% to 6.9% for the uninsured and from 2.7% to 5.5% for the insured (OR, 1.12-1.54; p < .01). CONCLUSIONS: Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.     

The missed patient with diabetes: how access to health care affects the detection of diabetes

OBJECTIVE—This study examined the association between access to health care and three classifications of diabetes status: diagnosed, undiagnosed, and no diabetes.RESEARCH DESIGN AND METHODS—Using data from the 1999–2004 National Health and Nutrition Examination Survey, we identified 110 “missed patients” (fasting plasma glucose >125 mg/dl but without diagnoses of diabetes), 704 patients with diagnosed diabetes, and 4,782 people without diabetes among adults aged 18–64 years. The population percentage undetected among adults with diabetes and the odds ratio of being undetected among adults who reported not having diabetes were compared between groups based on their access to health care.RESULTS—Among those with diabetes, the percentages having undetected diabetes were 42.2% (95% CI 36.7–47.7) among the uninsured, 25.9% (22.9–28.9) among the insured, 49.3% (43.0–55.6) for those uninsured >1 year, 38.7% (29.2–48.2) for those uninsured ≤1 year, and 24.5% (21.7–27.3) for those continuously insured over the past year. Type of insurance, number of times receiving health care in the past year, and routine patterns of health care utilization were also associated with undetected diabetes. Multivariate adjustment indicated that having undetected diabetes was associated with being uninsured (odds ratio 1.7 [95% CI 1.0–2.9]) and with being uninsured >1 year (2.6 [1.4–5.0]).CONCLUSIONS—Limited access to health care, especially being uninsured and going without insurance for a long period, was significantly associated with being a “missed patient” with diabetes. Efforts to increase detection of diabetes may need to address issues of access to care.In 2005, an estimated 6.2 million Americans had undiagnosed diabetes (1). Individuals with undiagnosed type 2 diabetes (type 2 diabetes accounts for 90–95% of all diabetes) have significantly higher risks for cardiovascular disease than do individuals without diabetes (2). Failure to diagnose diabetes prevents patients from receiving effective treatments and may have serious consequences, such as blindness, amputation, cardiovascular disease, and death (3). Interventions that can prevent or delay these complications cannot be promptly applied to patients with diabetes unless their disease has been detected (3). Timely detection, therefore, is of great importance, as it can reduce the human and economic cost of diabetes (2).A recent U.S. Census Bureau report estimated that 15.9%, or 46.6 million, of U.S. residents lacked health insurance in 2005 (4). Uninsured adults, compared with the insured, are much less likely to receive routine checkups or preventive services (5), tend to be more severely ill when diagnosed, and receive less therapeutic care (6). In addition to insurance coverage and the nature of coverage (7), absence of a physician or place for usual source of care is associated with lack of screening, follow-up care, and pharmacologic treatment for hypertension (8). Also, many insured individuals lack adequate access to health care or have only intermittent health insurance, and states of inadequate coverage are associated with lower use of preventive services (9,10). The absence of continuous insurance coverage can have a particularly severe impact, and a national study found that adults who were uninsured for a long period of time reported much greater unmet health needs than those who were insured (11). While being poor and uninsured is associated with delayed access to health care (12), higher-income adults lacking health care insurance have a decreased use of recommended health care services, and increased income does not attenuate the difference in use between uninsured and insured adults (13). Limited access to health care not only affects the use of preventive services (14) but also elevates the risk of a decline in overall health (15).To date, few studies have specifically examined the implications of having inadequate insurance coverage among individuals with diabetes. We have seen, however, that uninsured adults with diabetes are less likely to receive needed care and to effectively manage their disease, and those with health insurance have difficulty obtaining needed care when their coverage is inadequate (16,17). Medical organizations have addressed the importance of detecting diabetes (1,2,18), but the relationship between access to preventive services and the likelihood of having undetected diabetes has not been examined. Although two studies (19,20) investigated the relationship between socioeconomic status and the detection of diabetes and found that undiagnosed diabetes was not related to education or income, these studies did not examine the role that access to health care might play in detecting diabetes. Furthermore, no previous nationally representative studies have examined the association of access to health care with the detection of diabetes.In examining the relationship between access to preventive care and undetected diabetes, we sought to explore how access to health care relates to the detection of diabetes 1) in the diabetic population and 2) in the population who self-reported not having diabetes.     

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

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

Measuring the quality of depression care in a large integrated health system

BACKGROUND: Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement. OBJECTIVES: To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care. RESEARCH DESIGN: This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care. SUBJECTS: There were 12,678 patients eligible for depression care profiling. RESULTS: Adequate dosage was identified in 90%; 45% of patients had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), black race, and treatment exclusively in primary care. CONCLUSIONS: Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.     

Are preventable hospitalizations sensitive to changes in access to primary care? The case of the Oregon Health Plan

OBJECTIVE: To examine whether preventable hospitalization (PH) rates are sensitive to the impact of policies aimed at improving access, such as the Oregon Health Plan (OHP), which expanded Medicaid coverage to all adults with incomes under the federal poverty level. STUDY DESIGN: We conducted a retrospective, time series analysis of PH rates in Oregon from 1990 to 2000. We calculated hospitalization rates for ambulatory-care sensitive conditions for the Medicaid + uninsured population and compared average annual rates from 1990 to 1993 (pre-OHP implementation) to those from 1995 to 2000 (post-OHP implementation). We compared changes in PH rates over time in the Medicaid + uninsured group to changes in the non-Medicaid insured population. We standardized rates by age and sex and used logistic regression models to compare rates. RESULTS: Contrary to our hypothesis, annual PH rates in the Medicaid + uninsured population increased after the eligibility expansion, from an average of 46.1 to 54.9 per 10,000 persons. This rise was significant compared with the non-Medicaid insured population, who experienced a slight decline in annual PH rates, from 26.9 to 26.1 per 10,000 (P < 0.001, after adjusting for age, sex, and rates of unpreventable hospitalizations). The increase in overall PH rates for the Medicaid + uninsured population can be explained by an increase in PH rates for the newly insured group. CONCLUSIONS: Our results suggest that PH rates may vary not only with access to primary care (inversely) but also with access to hospital care (directly). The use of PH rates as a marker of health care access should take into account these dual influences. Limitations in available data may also contribute to perceived variation in PH rates unrelated to health care access.     

Understanding the demographic characteristics and health of medically uninsured patients

Objective

To determine demographic and diagnostic information about the medically uninsured patient population and compare it with that of the medically insured patient population at a primary care centre.

Design

Medical chart audit.

Setting

Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont.

Participants

Medically uninsured patients who were treated in the Department of Family and Community Medicine at St Michael’s Hospital from 2005 to 2009, as well as randomly selected patients who were insured through the Ontario Health Insurance Program.

Main outcome measures

The following information was obtained from patients’ medical charts: patient’s age, sex, and household income; if the patient had a specific diagnosis (ie, hypertension, type 2 diabetes mellitus, HIV, tuberculosis, substance addiction, or mental health disorder); if the patient accessed a specific category of primary care (ie, prenatal care or routine pediatric care); and the reason for the patient’s uninsured status.

Results

There was no significant difference in the mean age and sex distribution of insured and uninsured patients. The uninsured group had a significantly lower mean household income (P = .02). With the exception of HIV, there was no significant difference in the prevalence of the specific diagnoses studied or in the prevalence of accessing specific categories of primary care between insured and uninsured patients (P > .05). The prevalence of HIV was significantly greater in the uninsured group (24%) than in the insured group (4%) (P = .004). The largest proportion of uninsured patients lacked health insurance owing to the landed immigrant health insurance waiting period (27%), followed by individuals without permanent resident status in Canada (22%). A subgroup analysis of the uninsured, HIV-positive population revealed that the largest proportion of individuals (36%) lacked health insurance because they had no permanent resident status in Canada.

Conclusion

Uninsured and insured patients at the primary care centre did not differ significantly with respect to age and sex distribution; prevalence of hypertension, type 2 diabetes mellitus, tuberculosis, substance addiction, or mental health disorder; or the proportion who sought prenatal or routine pediatric care. The landed immigrant 3-month waiting period was the most common reason that uninsured patients lacked health insurance. Uninsured patients in this study lived in lower-income areas than insured patients did. This, combined with the increased prevalence of HIV in the uninsured group, might lead to a large number of uninsured, HIV-positive patients delaying seeking treatment and might have negative implications for public health.