Women veterans' healthcare delivery preferences and use by military service era: findings from the National Survey of Women Veterans

An Innovation to Expand the Reach of Peer Support: A Feasibility and Acceptability Study

INTRODUCTION

Peer support is a well-established part of veteran care and a cost-effective way to support individuals pursuing health behavior change. Common models of peer support, peer coaching, and mutual peer support have limitations that could be minimized by building on the strengths of each to increase the overall reach and effectiveness. We conducted a 12-week, proof-of-concept study to test the acceptability and feasibility of a hybrid model of peer support which supplements dyadic mutual peer support with as-needed peer coaching.

MATERIALS AND METHODS

We tested our novel peer support model within the context of cardiovascular disease (CVD) risk reduction as a support mechanism for the promotion of heart-healthy diet and exercise behaviors. We recruited peer buddies (participants who would be matched with each other to provide mutual support) with at least one uncontrolled CVD risk factor (i.e., blood pressure, weight, or diabetes) and peer coaches (individuals who would provide additional, as-needed support for peer buddies) with a recent history of CVD health behavior improvement. We aimed for 50% of peer buddies to be women to assess for potential gender differences in intervention engagement. Participants received didactic instruction during three group sessions, and peer dyads were instructed to communicate weekly with their peer buddy to problem-solve around action plans and behavioral goals. We tracked frequency of dyadic communication and conducted semi-structured interviews at the intervention's end to assess acceptability.

RESULTS

We recruited three peer coaches and 12 peer buddies. Ten buddies (five dyads) met at the first group session, and all were still in weekly contact with each other at week 12. Peer buddies had a mean of 8.75 out of 12 possible weekly peer buddy communications (range 6-15 in total). Peer coaches provided additional support to four participants over 12 weeks. Participants reported liking the intervention, including mixed-gender groups. Clarity and expectation setting around the role of peer coaches were important.

CONCLUSIONS

The supplementation of mutual peer support with as-needed peer coaching is an acceptable and feasible way to expand the potential reach and effectiveness of peer support for behavior change among veterans.

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

INTRODUCTION

Few studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.

METHODS

In a cross-sectional analysis, we linked Fiscal Year 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Health care Experiences of Patients-Patient Centered Medical Home (2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient-provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.

RESULTS

A greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01-1.10), provider communication (AOR, 1.08; 95% CI, 1.002-1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02-1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88-0.99).

CONCLUSION

For the most part, routine availability of women's health services in VA primary care clinics enhanced women's health care experiences. These empirical findings offer health care leaders evidence-based approaches for improving women's care experiences.

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION

Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers.

METHODS

We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics.

RESULTS

On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider.

CONCLUSIONS

Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

Timeliness and Adequacy of Prenatal Care Among Department of Veterans Affairs-Enrolled Veterans: The First Step May Be the Biggest Hurdle

INTRODUCTION

Little is known about access to and use of prenatal care by veterans using U.S. Department of Veterans Affairs (VA) maternity benefits. We compared the timeliness and adequacy of prenatal care by veteran status and payor.

STUDY DESIGN

We used VA clinical and admistrative data linked with California vital statistics patient discharge data to identify all births to VA-enrolled veterans and non-veterans between 2000 and 2012. Births were categorized based on veteran status and payor (non-veterans with Medicaid, non-veterans with private insurance, VA-enrolled veterans using VA maternity care benefits, and VA-enrolled veterans with other payor). Outcomes were timeliness of prenatal care (initiation before the end of the first trimester) and adequacy of prenatal care as measured by the Kotelchuck Index (inadequate, intermediate, adequate). Covariates included demographic, health, and pregnancy characteristics. We used generalized linear models and multinomial logistic regression to analyze the association of veteran status and payor with timeliness of prenatal care and adequacy of prenatal care, respectively.

RESULTS

We identified 6,196,432 births among VA-enrolled veterans (n = 17,495) and non-veterans (n = 6,178,937). Non-veterans using Medicaid had the lowest percentage of timely prenatal care (78.1%; n = 2,240,326), followed by VA-enrolled veterans using VA maternity care benefits (82.8%; n = 1,248). VA-enrolled veterans using VA maternity care benefits were the most likely to receive adequate prenatal care (92.0%; n = 1,365). Results remained consistent after adjustment.

CONCLUSIONS

This study provides key baseline data regarding access to and use of prenatal care by veterans using VA maternity benefits. Longitudinal studies including more recent data are needed to understand the impact of changing VA policy.

Baseline Characteristics from the Women Veterans Cohort Study: Gender Differences and Similarities in Health and Healthcare Utilization

Introduction: With the unprecedented expansion of women's roles in the U.S. military during recent (post-9/11) conflicts in Iraq and Afghanistan, the number of women seeking healthcare through the Veterans Health Administration (VHA) has increased substantially. Women Veterans often present as medically complex due to multiple medical, mental health, and psychosocial comorbidities, and consequently may be underserved. Thus, we conducted the nationwide Women Veterans Cohort Study (WVCS) to examine post-9/11 Veterans' unique healthcare needs and to identify potential disparities in health outcomes and care. Methods: We present baseline data from a comprehensive questionnaire battery that was administered from 2016 to 2019 to a national sample of post-9/11 men and women Veterans who enrolled in Veterans Affairs care (WVCS2). Data were analyzed for descriptives and to compare characteristics by gender, including demographics; health risk factors and symptoms of cardiovascular disease, chronic pain, and mental health; healthcare utilization, access, and insurance. Results: WVCS2 included 1,141 Veterans (51% women). Women were younger, more diverse, and with higher educational attainment than men. Women also endorsed lower traditional cardiovascular risk factors and comorbidities (e.g., weight, hypertension) and greater nontraditional cardiovascular risk factors (e.g., trauma, psychological symptoms). More women reported single-site pain (e.g., neck, stomach, pelvic) and multisite pain, but did not differ from men in posttraumatic stress disorder (PTSD) symptoms or treatment for PTSD. Women seek care at VHA medical centers more frequently, often combined with outside health services, but do not significantly differ from men in their insurance coverage. Conclusion: Overall, this investigation indicates substantial variation in risk factors, health outcomes, and healthcare utilization among post-9/11 men and women Veterans. Further research is needed to determine best practices for managing women Veterans in the VHA healthcare system.

The Problem of Veteran Homelessness: An Update for the New Decade

INTRODUCTION

There has been a decade-long federal commitment to prevent and end homelessness among U.S. military veterans. Substantial progress has been made; so, a question that stakeholders ask is: Is veteran homelessness still a problem?

METHODS

To answer this question, 2 different data sources were analyzed in 2020: (1) a nationally representative community survey of 4,069 veterans conducted in 2019 and (2) national administrative data from the U.S. Department of Veterans Affairs on >6 million healthcare and homeless services in 2019.

RESULTS

In the community sample, the lifetime prevalence of adult homelessness was 10.2%, with the highest prevalence found in participants aged 30-44 years (19.9% prevalence). In the Veterans Affairs administrative data, 4.2% of all Veterans Affairs service users used homeless services (n=290,515 Veterans Affairs homeless services); 27.9% of these were first-time Veterans Affairs homeless service users. Veterans who were racial/ethnic minorities were more likely to report any lifetime adult homelessness, more likely to be identified as homeless in Veterans Affairs records, and more likely to have used any Veterans Affairs homeless program. There was no sex difference in the lifetime prevalence of homelessness, but Veterans Affairs records showed that male veterans were more likely to be identified as homeless and to use homeless programs, suggesting possible underidentification of female veteran homelessness. Across age, sex, and racial/ethnic groups, 35.1% of Veterans Affairs homeless service users used emergency department services in the same year.

CONCLUSIONS

There is a continued need to dedicate resources to address veteran homelessness across sociodemographic groups, and these data serve as a benchmark before and after the onset of the COVID-19 pandemic.

Experiences and Knowledge of US Department of Veterans Affairs Clinical Services, Research, and Education: Results From a National Survey of Veterans

OBJECTIVE

This study examined (1) sociodemographic, health, and psychosocial characteristics associated with using the Department of Veterans Affairs (VA) health care system as a primary health care provider; (2) veterans' experience and knowledge of VA clinical services, research, and education; and (3) veteran characteristics associated with VA experience and knowledge.

DESIGN

A nationally representative survey was conducted in 2018; eligibility criteria for participation were adults aged 18 years or older, currently living in the United States, and having served on active duty in the US military.

SETTING

The survey was conducted online using large national survey panels.

PARTICIPANTS

A sample of 1002 veterans across 49 states participated.

MAIN OUTCOME MEASURES

The survey assessed experience and knowledge of majority of VA clinical services, research, and education.

RESULTS

One-quarter of the total sample reported that the VA was their primary health care provider. Among veterans who had ever used VA health care, the majority (68%) reported overall high satisfaction with VA health care but also agreed with "privatizing parts of the VA" (70%). The majority (51%-73%) of veterans reported knowledge of major VA clinical services, with the exception of comprehensive management for chronic pain (24%) and treatment of opioid use disorders (31%). One-quarter to one-half also reported knowledge of several VA research and education centers. Less than 10% of veterans reported having ever used a VA mobile app.

CONCLUSIONS

The US veterans generally reported positive experiences and good knowledge of VA services and resources. Greater awareness of available VA services for chronic pain and opioid use disorders, as well as VA mobile apps, may help promote more comprehensive care in this population.

Sleep apnea in women veterans: results of a national survey of VA health care users

STUDY OBJECTIVES

The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population.

METHODS

A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities.

RESULTS

Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy.

CONCLUSIONS

Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.

Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans

IMPORTANCE

Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care.

OBJECTIVE

To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020.

EXPOSURES

Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year.

MAIN OUTCOMES AND MEASURES

Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration.

RESULTS

This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001).

CONCLUSIONS AND RELEVANCE

While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.

Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy

BACKGROUND

Researchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans.

METHODS

This study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy.

RESULTS

Lifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11-2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19-2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15-2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36-0.96), younger age (OR, 0.95; 95% CI, 0.91-0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37-0.84) were associated with a decreased likelihood of actual VA service use during pregnancy.

CONCLUSIONS

Results emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.

Mental Health and Obesity Among Veterans: A Possible Need for Integrated Care

OBJECTIVE

The goal was to examine psychiatric diagnosis rates among a national cohort of primary care patients with and without obesity.

METHODS

The cohort was derived from national Veterans Health Administration data (women, N=342,262; men, N=4,524,787). Sex-stratified descriptive statistics characterized psychiatric diagnosis rates. Chi-square tests determined whether diagnosis rates differed by obesity status (α=0.001).

RESULTS

Rates of any psychiatric diagnosis were higher among women than among men and among people with obesity versus without obesity (women, 53.9% vs. 50.4%; men, 37.9% vs. 35.2%). Depression and posttraumatic stress disorder diagnosis rates were higher for people with obesity, and substance use disorder diagnosis rates were lower for people with obesity. Anxiety diagnosis rates were slightly lower among women with obesity versus women without obesity.

CONCLUSIONS

Programs simultaneously addressing weight management and mental health could address the psychiatric comorbidities observed among people with obesity. Women are most likely to need these services.

The role of healthcare system hassles in delaying or forgoing care

BACKGROUND

Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or "hassles" and delaying or forgoing care has not been assessed.

METHODS

We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse.

RESULTS

Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care.

CONCLUSION

Addressing healthcare system hassles could yield unexpected benefits to realized access.

Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States

BACKGROUND

Research on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking.

METHODS

This cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015.

RESULTS

Results of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22-1.71), back pain (AOR, 1.83; 95% CI, 1.56-2.14), diabetes (AOR, 1.42; 95% CI, 1.03-1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80-3.98), major depression (AOR, 1.78; 95% CI, 1.53-2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34-2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts.

CONCLUSIONS

OIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers' increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.

Gender-based Differences among 1990-1991 Gulf War Era Veterans: Demographics, Lifestyle Behaviors, and Health Conditions

OBJECTIVE

The 1990-1991 Gulf War employed more women servicemembers than any prior conflict. Gender-based differences among veterans of this era have yet to be explored. This study is among the first and most recent to stratify Gulf War veteran demographics, lifestyle factors, and self-reported diagnoses by gender.

METHODS

Data from the cross-sectional Gulf War Era Cohort and Biorepository pilot study (n = 1,318; collected between 2014 and 2016), including users and nonusers of the Veterans Health Administration, were used to calculate demographics and adjusted odds ratios.

RESULTS

Women veterans were oversampled and comprised approximately 23% of the sample. Women reported similar rates of Veterans Health Administration use (44%) and deployment (67%) as men (46% and 72%, respectively). Women were less likely than men to report frequent alcohol use (adjusted odds ratio [aOR], 0.59; 95% confidence interval [CI], 0.43-0.81; p = .0009) or have a history of smoking (aOR, 0.65; 95% CI, 0.49-0.84; p = .0014). Among common health conditions, women were more likely than men to report a diagnosis of osteoporosis (aOR, 4.24; 95% CI, 2.39-7.51; p < .0001), bipolar disorder (aOR, 2.15; 95% CI, 1.15-4.04; p = .0167), depression (aOR, 2.39; 95% CI, 1.81-3.16; p < .0001), irritable bowel syndrome (aOR, 2.10; 95% CI, 1.43-3.09; p = .0002), migraines (aOR, 2.96; 95% CI, 2.18-4.01; p < .0001), asthma (aOR, 1.86; 95% CI, 1.29-2.67; p = .0008), and thyroid problems (aOR, 4.60; 95% CI, 3.14-6.73; p < .0001). Women were less likely than men to report hypertension (aOR, 0.55; 95% CI, 0.41-0.72; p < .0001), tinnitus (aOR, 0.46; 95% CI, 0.33-0.63; p < .0001), and diabetes (aOR, 0.44; 95% CI, 0.28-0.69; p = .0003).

CONCLUSIONS

Health differences exist between female and male veterans from the 1990-1991 Gulf War. Gender-specific analyses are needed to better understand the unique health care needs of Gulf War Era veterans and direct future research.

Innovations for integrated care: The Association of Medicine and Psychiatry recognizes new models

This editorial looks at the current state of the integration of medicine and psychiatry in clinical practice. We note selected recent triumphs and barriers to implementing integrated care, highlighting some gaps and priorities for future innovations. In contrast to the relatively more orderly culture of health services research, where some notable innovations in integrated care were funded, tested, and published, the health care marketplace can be a difficult place to identify and track the innovations that could shape health care reform. Recognizing the need to find, describe, and disseminate the most innovative models in integrated care, the Association of Medicine and Psychiatry (AMP) launched in 2016 the Innovative Models for Integrated Care Awards. Although many service innovations solve local problems, some can also act as models to be adopted in multiple settings. The projects that win AMP Innovative Models for Integrated Care Awards are selected for their innovativeness, their clinical importance, their generalizability, and their effectiveness. We briefly describe here the four models that earned these awards at the 2017 AMP Annual Meeting. They demonstrate innovations across a range of settings and populations: inpatient general hospital patients under constant observation in New York, severely mentally ill patients in a federally qualified health center in San Francisco, outpatients in a VA women's health center in Chicago, and HIV patients in an academic infectious disease clinic in Charleston, south Carolina. These model descriptions aim to encourage the implementation of innovative models that advance the integration of medicine and psychiatry.

Use of alcohol as a sleep aid, unhealthy drinking behaviors, and sleeping pill use among women veterans

OBJECTIVES

Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use.

DESIGN AND SETTING

National cross-sectional population-based residential mail survey on sleep and other symptoms.

PARTICIPANTS

Random sample of women veteran VA users who completed a postal survey (N = 1533).

INTERVENTIONS

None.

MEASUREMENTS

The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month.

RESULTS

A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11).

CONCLUSIONS

Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.

Impact of Deployment on Reproductive Health in U.S. Active-Duty Servicewomen and Veterans

Reproductive-age women are a fast-growing component of active-duty military personnel who experience deployment and combat more frequently than previous service-era women Veterans. With the expansion of the number of women and their roles, the United States Departments of Defense and Veterans Affairs have prioritized development and integration of reproductive services into their health systems. Thus, understanding associations between deployments or combat exposures and short- or long-term adverse reproductive health outcomes is imperative for policy and programmatic development. Servicewomen and women Veterans may access reproductive services across civilian and military or Veteran systems and providers, increasing the need for awareness and communication regarding deployment experiences with a broad array of providers. An example is the high prevalence of military sexual trauma reported by women Veterans and the associated mental health diagnoses that may lead to a lifetime of high risk-coping behaviors that increase reproductive health risks, such as sexually transmitted infections, unintended pregnancies, and others. Care coordination models that integrate reproductive healthcare needs, especially during vulnerable times such as at the time of military separation and in the immediate postdeployment phase, may identify risk factors for early intervention with the potential to mitigate lifelong risks.

Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding by Primary Care Providers in the Veterans Health Administration

BACKGROUND

Abnormal uterine bleeding (AUB) is a common women's health complaint. However, the quality of primary care (PC) management of AUB is unknown. Our objective was to develop quality indicators for Veterans Health Administration (VA) PC assessment and management of AUB.

METHODS

We drafted candidate indicators based on comprehensive review of the scientific literature, including published consensus guidelines. Then, we convened a national panel of nine experts including PC providers, obstetrician-gynecologists, VA policy stakeholders, and quality measurement experts, and used a modified Delphi panel process. First, panelists individually rated 19 candidate indicators, using 9-point scales, on three metrics: consistency with established guidelines, importance to women's health, and reliability of measurement from VA electronic health records. Panelists then discussed the indicators. Finally, panelists re-rated revised indicators using the same metrics. Indicators were selected if final median ratings were ≥7 on each 9-point scale, without dispersion in ratings.

RESULTS

Eighteen indicators were selected. Three focused on assessing need for emergency care (e.g., profuse bleeding or pregnancy). Three addressed ascertaining key aspects of the medical history (e.g., endometrial cancer risk). Two addressed performing a physical examination (e.g., pelvic examination). Six addressed indications for diagnostic studies and specialty care referrals, (e.g., transvaginal ultrasound examination). Four addressed initiation of treatment and counseling (e.g., hormone therapy).

CONCLUSIONS

We developed quality indicators for PC assessment and management of AUB that span reproductive and postmenopausal life phases. Applying these indicators in VA and other health systems with integrated electronic health records can assess need for, and effects of, AUB quality improvement programs.

Guideline Adherence of Veterans Health Administration Primary Care for Abnormal Uterine Bleeding

BACKGROUND

Abnormal uterine bleeding (AUB) is common among primary care patients. We assessed the extent to which Veterans Health Administration (VA) primary care patients with AUB are receiving guideline-adherent primary care.

METHODS

We identified women with AUB presenting to primary care providers across four VA health care systems from June 2013 to September 2015. We performed a structured abstraction of electronic medical record data for 15 indicators of guideline-adherent AUB care. We determined whether documented care was guideline-adherent and compared adherence of care by primary care providers by VA Designated Women's Health Provider status and by volume of clinical encounters with women veterans.

RESULTS

Across 305 episodes of AUB, 53% of the care was guideline adherent. There was high adherence with documenting menopausal status (98%), ordering diagnostic studies and referrals for postmenopausal women (92%), and documenting bleeding patterns (87%). There was lower adherence with documenting whether there was active bleeding (55%), performing thyroid testing (47%), performing a pelvic examination (42%), ordering diagnostic studies and referrals in younger women with increased endometrial cancer risk (40%), assessing for pregnancy (32%), assessing for cervical motion, uterine, or adnexal tenderness in patients with intrauterine devices (30%), and assessing for elevated endometrial cancer risk (6%). There were no significant differences in overall guideline adherence between primary care providers who were, versus were not, VA Designated Women's Health Providers, or by provider volume of encounters with women veterans.

CONCLUSIONS

VA primary care has high guideline adherence when caring for postmenopausal women with AUB. Quality improvement and educational initiatives are needed to improve primary care for AUB in younger women veterans.

Sleep Disorders in Women Veterans

Sleep disorders are common among women veterans and contribute to poor functioning and quality of life. Studies show that women veterans are particularly prone to insomnia, sleep-disordered breathing, and insufficient sleep. Standard cognitive behavioral therapy for insomnia (CBT-I) should be viewed as first-line therapy for insomnia disorder, and women veterans should be screened and treated for sleep-disordered breathing. Behavioral and lifestyle factors contributing to insufficient sleep should also be addressed. Challenges exist in diagnosing and treating sleep disorders in women veterans, in part because of high rates of psychiatric comorbidities, such as posttraumatic stress disorder and depression.

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

Teaching Patient-Centered Care Through the Veterans History Project

Determining the best ways to teach military culture and the veteran experience to nursing students and new nurses is an essential component in developing a culturally sensitive nursing workforce. The purpose of this article is to describe a theory-driven, experiential learning approach to integrating the Veterans History Project into the curricula for a postbaccalaureate nurse residency program. Participants acknowledged that this educational project better prepared them to care for the veteran population.

Patient-Rated Access to Needed Care: Patient-Centered Medical Home Principles Intertwined

BACKGROUND

Primary care teams can facilitate access to care by helping patients to determine whether and when care is needed, and coordinating care across multiple clinicians and settings. Appointment availability metrics may or may not capture these contributions, but patients' own ratings of their access to care provide an important alternative view of access that may be more closely related to these key functions of care teams.

PROCEDURES

We used a 2015 telephone survey of 1,395 women veterans to examine associations between key care team functions and patient-rated access to needed care. The care team functions were care coordination, in-person communication (between patient and care team), and phone communication (timely answers to health questions). We controlled for sociodemographics, health status, care settings, and other experience of care measures.

KEY FINDINGS

Overall, 74% of participants reported always or usually being able to see a provider for routine care, and 68% for urgent care. In adjusted analyses, phone communication was associated with better ratings of access to routine care (odds ratio [OR], 4.31; 95% CI, 2.65-6.98) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Care coordination was also associated with better ratings of access to routine care (OR, 1.66; 95% CI, 1.01-2.74) and urgent care (OR, 2.26; 95% CI, 1.23-4.18). Associations with in-person communication were not significant.

CONCLUSIONS

Access, communication, and care coordination are interrelated. Approaches to improving access may prove counterproductive if they compromise the team's ability to coordinate care, or diminish the team's role as a primary point of contact for patients.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

A Health Profile of Senior-Aged Women Veterans: A Latent Class Analysis of Condition Clusters

Background and Objectives

This study characterizes the multiple morbidities experienced by senior-aged women Veterans so that the Veterans Health Administration (VHA) and other health care systems may be better prepared to meet the health care needs of this growing cohort.

Research Design and Methods

Using the VHA’s Corporate Data Warehouse, we conducted a retrospective observational study of the 38,597 female veteran patients who were at least 65 years old and received care in the VHA during 2013 and 2014. We use a latent class analysis model to cluster diagnoses associated with inpatient and outpatient events over the years.

Results

The senior-aged women Veterans are characterized by six major classes of disease clusters. We defined these classes as: Healthy (16.24% of the cohort); Ophthalmological Disorders (13.84%); Musculoskeletal Disorders (14.22%); At Risk for Cardiovascular Disease (37.53%); Diabetic with Comorbidities (9.05%); and Multimorbid (9.12%). The patterns and prevalence of these condition classes vary by race, age, and marital status.

Discussion and Implications

Each of the six clusters can be used to develop clinical practice guidelines that are appropriate for senior-aged women Veterans. Consistent with past literature, the most common conditions in this cohort are hypertension and hyperlipidemia; together they form the most common class, “At Risk of Cardiovascular Disease (CVD)”. Results also show evidence of race-related disparities, with Blacks being more likely to be in the highest risk classes. Also, members of the cohort who are currently married having improved chances of being in the healthy class. And finally, we see a “healthy survivor” effect with the oldest women in our cohort having low overall rates of disease.

A Review of Epidemiologic Studies of the Health of Gulf War Women Veterans

INTRODUCTION

In the 25 years since the 1990-1991 Gulf War (GW), studies have evaluated Gulf War Illness (GWI), sometimes referred to as medically unexplained multi symptom illness, and other medical and neurological conditions in women GW veterans.

MATERIALS AND METHODS

In this article, we review epidemiologic studies of the health of women who served in the 1990-1991 GW based upon bibliographic searches in PubMed and CINAHL with relevant search terms through September 2015.

RESULTS

A total of 56 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, a total of 21 relevant studies were identified. Results from some studies, but not all, suggest that GWI is more common in women GW veterans than their male counterparts. Few studies of GW veterans focused on women's health. A small number of studies suggested excess rates of woman's health problems, e.g., breast cysts, abnormal Papanicolaou (Pap) smears, yeast infections, and bladder infections. Several studies have identified significantly elevated rates of birth defects and adverse reproductive outcomes among GW veterans. However, findings have varied with different study designs and sample sizes, with some studies showing elevated risks of stillbirths, miscarriages, and/or birth defects and others have not. In some studies, participants reported increased risks of ectopic pregnancies and spontaneous abortions.

CONCLUSION

Further research is needed to provide a comprehensive picture of the health of women GW veterans and to examine a broad range of women's health issues including adverse reproductive outcomes. Some deployment-related health problems only become apparent decades later and other conditions may worsen or improve over time. Assessments are needed of current health status, changes in health symptoms and conditions over time, and possible differences in health outcomes associated with specific experiences and exposures during the war. Future studies would be strengthened by assessing GWI symptom patterns that may be specific to women veterans, examine diagnosed medical conditions among women veterans, and evaluate changes in women's health over time, including changes potentially associated with menopause and age.

The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans

BACKGROUND

Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services.

OBJECTIVES

To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients.

DESIGN

Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant.

PARTICIPANTS

Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients).

MAIN MEASURES

We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations.

KEY RESULTS

Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%).

CONCLUSIONS

Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey

OBJECTIVES

Insomnia is a significant public health concern known to particularly impact women and the veteran population; however, rates of insomnia disorder among women veterans are not known.

METHOD

Women veterans who had received health care at VA Greater Los Angeles Healthcare System between 2008 and 2010 and resided within 25 miles of the facility were sent a postal survey assessing sleep, demographics, and other related patient characteristics.

RESULTS

A total of 660 women (43.1% of potential responders) returned the postal survey and provided sufficient information for insomnia diagnosis. On average, women reported 6.2 hours of sleep per night. The prevalence of insomnia, determined according to diagnostic criteria from the International Classification of Sleep Disorders-2, was 52.3%. Women with insomnia reported more severely disturbed sleep, and more pain, menopausal symptoms, stress/worries, and nightmares compared with women without insomnia. There was a quadratic relationship between age and insomnia with women in their mid-40s, most likely to have insomnia.

CONCLUSIONS

This survey study found that insomnia symptoms were endorsed by more than one-half of the women veterans in this sample of VA users, highlighting the critical need for enhanced clinical identification and intervention. Further research is needed to establish national rates of insomnia among women veterans and to improve access to evidence-based treatment of insomnia disorder.

Drivers of Continuing Education Learning Preferences for Veterans Affairs Women's Health Primary Care Providers

INTRODUCTION

Documented gaps in health professionals' training in women's health are a special concern for continuing education (CE). In the Veterans Affairs (VA) health care system, women veterans are a numerical minority, preferably assigned to designated women's health primary care providers (DWHPs). DWHPs need to maintain their knowledge and skills in women's health topics, in addition to general internal medicine topics. We explored drivers of VA DWHPs' learning preferences for women's health topics-ie, factors which influence greater and lesser learning interest.

METHODS

We conducted semistructured telephone interviews with DWHPs across six VA health care systems. Interviews were audio recorded, transcribed, and coded in ATLAS.ti. We synthesized results by grouping relevant coded sections of text to form emergent themes.

RESULTS

Among the 31 DWHPs interviewed, reported drivers of learning interests among women's health topics were (1) high frequency of clinical incidence of particular issues; (2) perceived appropriateness of particular issues for management in primary care settings; and (3) perceived appropriateness of particular issues for partial management in primary care. Lower interest in particular women's health topics was associated with (1) perceived existing competency or recent training in an issue and (2) perceived need for specialty care management of an issue.

DISCUSSION

Understanding drivers of DWHPs' CE learning priorities lays a foundation for developing CE programming that will be of interest to women's health primary care providers. Attention to drivers of learning interests may have applicability beyond women's health, suggesting a general approach for CE programming that prioritizes high-volume topics within the practice scope of target providers.

Aging Well Among Women Veterans Compared With Non-Veterans in the Women's Health Initiative

PURPOSE OF THE STUDY

To examine whether Veteran status influences (a) women's survival to age 80 years without disease and disability and (b) indicators of successful, effective, and optimal aging at ages 80 years and older.

DESIGN AND METHODS

The Women's Health Initiative (WHI) enrolled 161,808 postmenopausal women aged 50-79 years from 1993 to 1998. We compared successful aging indicators collected in 2011-2012 via mailed questionnaire among 33,565 women (921 Veterans) who reached the age of 80 years and older, according to Veteran status. A second analysis focused on women with intact mobility at baseline who could have reached age 80 years by December 2013. Multinominal logistic models examined Veteran status in relation to survival to age 80 years without major disease or mobility disability versus having prevalent or incident disease, having mobility disability, or dying prior to age 80 years.

RESULTS

Women Veterans aged 80 years and older reported significantly lower perceived health, physical function, life satisfaction, social support, quality of life, and purpose in life scale scores compared with non-Veterans. The largest difference was in physical function scores (53.0 for Veterans vs 59.5 for non-Veterans; p < .001). Women Veterans were significantly more likely to die prior to age 80 years than non-Veteran WHI participants (multivariate adjusted odds ratio = 1.20; 95% confidence interval, 1.04-1.38). In both Veteran and non-Veteran women, healthy survival was associated with not smoking, higher physical activity, healthy body weight, and fewer depressive symptoms.

IMPLICATIONS

Intervening upon smoking, low physical activity, obesity, and depressive symptoms has potential to improve chances for healthy survival in older women including Veterans.

Trajectories in Physical Activity and Sedentary Time Among Women Veterans in the Women's Health Initiative

PURPOSE OF THE STUDY

Trajectories of physical activity (PA) and sedentary time (ST) after military separation are likely important determinants of women's health outcomes later in life, because low PA and high ST are known contributors to premature mortality risk. Our objective was to compare longitudinal trajectories of recreational PA and ST between Veteran and non-Veteran postmenopausal women from the Women's Health Initiative (WHI).

DESIGN AND METHODS

Women Veteran (n = 3,719) and non-Veteran (n = 141,800) WHI participants were included. Self-reported participation in recreational PA, converted to metabolic equivalent (MET)-hours/week, was prospectively assessed over 8 years. Self-reported ST, defined as hours/day sitting or lying down, was collected at baseline and at Years 3 and 6. Generalized estimating equations were used to compare trajectories of PA and ST between Veterans and non-Veterans, adjusted for demographics and lifestyle behaviors.

RESULTS

Veterans had higher baseline PA than non-Veterans (13.2 vs 12.5 MET-hours/week, p = .03). PA declined for both groups, with a steeper decline among Veterans (change/visit year -0.19 vs -0.02 MET-hours/week; interaction p < .001). At baseline, Veterans and non-Veterans had similar levels of ST (107.2 vs 105.9 hours/week, p = 0.42). Over time, ST remained stable among Veterans but declined slightly among non-Veterans (change/visit year -0.19 vs -0.49 hours/week; interaction p = .01).

IMPLICATIONS

The less favorable longitudinal trajectories of PA and ST we observed for women Veterans may contribute to worse health among these individuals later in life. Understanding barriers to enhancing PA and reducing ST in women Veterans could lead to more effective approaches to intervening on these health behaviors.

Military Generation and Its Relationship to Mortality in Women Veterans in the Women's Health Initiative

PURPOSE OF THE STUDY

Women's military roles, exposures, and associated health outcomes have changed over time. However, mortality risk-within military generations or compared with non-Veteran women-has not been assessed. Using data from the Women's Health Initiative (WHI), we examined all-cause and cause-specific mortality by Veteran status and military generation among older women.

DESIGN AND METHODS

WHI participants (3,719 Veterans; 141,802 non-Veterans), followed for a mean of 15.2 years, were categorized into pre-Vietnam or Vietnam/after generations based on their birth cohort. We used cox proportional hazards models to examine the association between Veteran status and mortality by generation.

RESULTS

After adjusting for sociodemographic characteristics and WHI study arm, all-cause mortality hazard rate ratios (HRs) for Veterans relative to non-Veterans were 1.16 (95% CI: 1.09-1.23) for pre-Vietnam and 1.16 (95% CI: 0.99-1.36) for Vietnam/after generations. With additional adjustment for health behaviors and risk factors, this excess mortality rate persisted for pre-Vietnam but attenuated for Vietnam/after generations. After further adjustment for medical morbidities, across both generations, Veterans and non-Veterans had similar all-cause mortality rates. Relative to non-Veterans, adjusting for sociodemographics and WHI study arm, pre-Vietnam generation Veterans had higher cancer, cardiovascular, and trauma-related morality rates; Vietnam/after generation Veterans had the highest trauma-related mortality rates (HR = 2.93, 1.64-5.23).

IMPLICATIONS

Veterans' higher all-cause mortality rates were limited to the pre-Vietnam generation, consistent with diminution of the healthy soldier effect over the life course. Mechanisms underlying Vietnam/after generation Veteran trauma-related mortality should be elucidated. Efforts to modify salient health risk behaviors specific to each military generation are needed.

Hysterectomy and Bilateral Salpingo-Oophorectomy: Variations by History of Military Service and Birth Cohort

INTRODUCTION

Little is known about hysterectomy and bilateral salpingo-oophorectomy (BSO), which are associated with both health risks and benefits, among women Veterans.

PURPOSE OF THE STUDY

To compare the prevalence of hysterectomy with or without BSO, and early hysterectomy, between postmenopausal Veterans and non-Veterans.

DESIGN AND METHODS

We used baseline data from the Women's Health Initiative Clinical Trial and Observational Study. Multinomial logistic regression models examined differences in the prevalence of hysterectomy (neither hysterectomy nor BSO, hysterectomy without BSO, and hysterectomy with BSO) between Veterans and non-Veterans. Generalized linear models were used to determine whether early hysterectomy (before age 40) differed between Veterans and non-Veterans. Analyses were stratified by birth cohort (<65, ≥65 years at enrollment).

RESULTS

The unadjusted prevalence of hysterectomy without BSO was similar among Veterans and non-Veterans in both birth cohorts (<65: 22% vs 21%; ≥65: 22% vs 21%). The unadjusted prevalence of hysterectomy with BSO was equivalent among Veterans and non-Veterans in the >65 cohort (21%), but higher among Veterans in the <65 cohort (22% vs 19%). In adjusted analyses, although no differences were observed in the >65 cohort, Veterans in the <65 cohort had higher odds of hysterectomy without BSO (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.03, 1.36) and with BSO (OR 1.26, 95% CI 1.10, 1.45), as well as elevated risk of early hysterectomy (relative risk 1.32, 95% CI 1.19, 1.47), compared with non-Veterans.

IMPLICATIONS

Aging women Veterans may have higher prevalence of hysterectomy and BSO than non-Veterans. This information contributes to understanding the health needs and risks of women Veterans and can inform clinical practice and policy for this population.

E-consult implementation: lessons learned using consolidated framework for implementation research

OBJECTIVES

In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR).

STUDY DESIGN

Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample.

METHODS

We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites.

RESULTS

Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs.

CONCLUSIONS

By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.

Prospective Analysis of Health and Mortality Risk in Veteran and Non-Veteran Participants in the Women's Health Initiative

BACKGROUND

The health of postmenopausal women veterans is a neglected area of study. A stronger empirical evidence base is needed, and would inform the provision of health care for the nearly 1 million U.S. women veterans currently 50 years of age or older. To this end, the present work compares salient health outcomes and risk of all-cause mortality among veteran and non-veteran participants of the Women's Health Initiative (WHI).

METHODS

This study features prospective analysis of long-term health outcomes and mortality risk (average follow-up, 8 years) among the 3,706 women veterans and 141,009 non-veterans who participated in the WHI Observational Study or Clinical Trials. Outcome measurements included confirmed incident cases of cardiovascular disease (CVD), cancer, diabetes, hip fractures, and all-cause mortality.

RESULTS

We identified 17,968 cases of CVD, 19,152 cases of cancer, 18,718 cases of diabetes, 2,817 cases of hip fracture, and 13,747 deaths. In Cox regression models adjusted for age, sociodemographic variables, and health risk factors, veteran status was associated with significantly increased risk of all-cause mortality (hazard ratio [HR], 1.13; 95% CI, 1.03-1.23), but not with risk of CVD (HR, 1.00; 95% CI, 0.90-1.11), cancer (HR, 1.04; 95% CI, 0.95-1.14), hip fracture (HR, 1.16; 95% CI, 0.94-1.43), or diabetes (HR, 1.00; 95% CI, 0.89-1.1).

CONCLUSIONS

Women veterans' postmenopausal health, particularly risk for all-cause mortality, warrants further consideration. In particular, efforts to identify and address modifiable risk factors associated with all-cause mortality are needed.

Women Veterans' Pathways to and Perspectives on Veterans Affairs Health Care

BACKGROUND

We examined Veterans Affairs (VA) health care experiences among contemporary women veteran patients receiving care at a VA medical center. Specifically, we examined women veteran patients' satisfaction with VA care along dimensions in line with patient-centered medical home (patient-aligned care teams [PACT] in VA) priorities, and pathways through which women initially accessed VA care.

METHODS

We used a mixed methods research design. First, 249 racially diverse women (ages 22-64) who were past-year users of primary care at a VA medical center completed interviewer-administered surveys in 2012 assessing ratings of satisfaction with care in the past year. We then conducted in-depth qualitative interviews of a subset of women surveyed (n = 25) to gain a deeper understanding of perspectives and experiences that shaped satisfaction with care and to explore women's initial pathways to VA care.

RESULTS

Ratings of satisfaction with VA care were generally high, with some variation by demographic characteristics. Qualitative interviews revealed perceptions of care centered on the following themes: 1) barriers to care delay needed medical care, while innovative care models facilitate access, 2) women value communication and coordination of care, and 3) personalized context of VA care, including gender sensitive care shapes women's perceptions. Pathways to VA care were characterized by initial delays, often attributable to lack of knowledge or negative perceptions of VA care. Informal social networks were instrumental in helping women to overcome barriers.

CONCLUSIONS

Findings highlight convergence of women's preferences with PACT priorities of timely access to care, provider communication, and coordination of care, and suggest areas for improvement. Outreach is needed to address gaps in knowledge and negative perceptions. Initiatives to enhance women veterans' social networks may provide an information-sharing resource.

Antiepileptic drug prescribing patterns in Iraq and Afghanistan war veterans with epilepsy

OBJECTIVE

We examined patterns of antiepileptic drug (AED) use in a cohort of Iraq/Afghanistan war veterans (IAVs) who were previously identified as having epilepsy. We hypothesized that clinicians would be more likely to prescribe newer AEDs and would select specific AEDs to treat seizures based on patient characteristics including gender and comorbidities.

METHODS

From the cohort of IAVs previously identified with epilepsy between fiscal years 2009 and 2010, we selected those who received AEDs from the Veterans Health Administration in FY2010. Regimens were classified as monotherapy or polytherapy, and specific AED use was examine overall and by gender. Multivariable logistic regression examined associations of age; gender; race/ethnicity; medical, psychiatric, and neurological comorbidities; and receipt of neurology specialty care associated with the six most commonly used AEDs.

RESULTS

Among 256,284 IAVs, 2123 met inclusion criteria (mean age: 33years; 89% men). Seventy-two percent (n=1526) received monotherapy, most commonly valproate (N=425) and levetiracetam (n=347). Sixty-one percent of those on monotherapy received a newer AED (levetiracetam, topiramate, lamotrigine, zonisamide, oxcarbazepine). Although fewer women than men received valproate, nearly 90% (N=45) were of reproductive age (≤45years). Antiepileptic drug prescribing patterns were associated with posttraumatic stress disorder, bipolar disorder, cerebrovascular disease, dementia/cognitive impairment, headache, and receipt of neurological specialty care (all p<0.01).

SIGNIFICANCE

In this cohort of veterans with epilepsy, most received AED monotherapy and newer AEDs. Prescribing patterns were different for men and women. The patterns observed between AEDs and neurological/psychiatric comorbidities suggest that clinicians are practicing rational prescribing.

Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel

BACKGROUND

Women Veterans are a significant minority of users of the VA healthcare system, limiting provider and staff experience meeting their needs in environments historically designed for men. The VA is nonetheless committed to ensuring that women Veterans have access to comprehensive care in environments sensitive to their needs.

OBJECTIVES

We sought to determine what aspects of care need to be tailored to the needs of women Veterans in order for the VA to deliver gender-sensitive comprehensive care.

RESEARCH DESIGN

Modified Delphi expert panel process.

SUBJECTS

Eleven clinicians and social scientists with expertise in women's health, primary care, and mental health.

MEASURES

Importance of tailoring over 100 discrete aspects of care derived from the Institute of Medicine's definition of comprehensive care and literature-based domains of sex-sensitive care on a 5-point scale.

RESULTS

Panelists rated over half of the aspects of care as very-to-extremely important (median score 4+) to tailor to the needs of women Veterans. The panel arrived at 14 priority recommendations that broadly encompassed the importance of (1) the design/delivery of services sensitive to trauma histories, (2) adapting to women's preferences and information needs, and (3) sex awareness and cultural transformation in every facet of VA operations.

CONCLUSIONS

We used expert panel methods to arrive at consensus on top priority recommendations for improving delivery of sex-sensitive comprehensive care in VA settings. Accomplishment of their breadth will require national, regional, and local strategic action and multilevel stakeholder engagement, and will support VA's national efforts at improving customer service for all Veterans.

Alcohol and drug misuse, abuse, and dependence in women veterans

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

National prevalence and correlates of alcohol misuse in women veterans

Our goal was to estimate the prevalence and correlates of alcohol misuse in women veterans and to assess the associations between alcohol misuse and mental health (MH) care utilization in a group comprising both Veterans Health Administration (VA) healthcare system users and non-users. We assessed alcohol misuse using survey-based AUDIT-C scores. The prevalence of alcohol misuse was 27% in VA users and 32% in non-users. Prevalence rates were higher for VA users who were younger, served in OEF/OIF, or had combat exposure and for VA non-users who screened positive for posttraumatic stress disorder or sexual assault in the military. In contrast to VA users, VA non-users with alcohol misuse had a low prevalence of past-year MH care despite having indications of MH care need. Our results on alcohol misuse prevalence, its correlates, and its association with MH care may aid program planning and resource allocation in VA and non-VA settings.

Anticipating the traumatic brain injury-related health care needs of women veterans after the Department of Defense change in combat assignment policy

BACKGROUND

Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI).

METHODS

The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE).

FINDINGS

Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs.

CONCLUSION

As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting.