Optimizing Data on Race and Ethnicity for Veterans Affairs Patients

Emergency department visits at Veterans Health Administration hospitals related to alcohol intoxication: A ten-year retrospective

We sought to quantify and describe the volume of emergency department visits related to alcohol intoxication at the Veterans Health Administration (VHA), the largest healthcare system in the United States. This is a retrospective cohort study of patients with VHA emergency department visits for alcohol intoxication from 2010 to 2019 as identified via ICD-9/10 code and/or serum ethanol concentration >50 mg/dL. Encounters were identified and demographic and clinical data were acquired by automated query of the VHA Corporate Data Warehouse. Descriptive statistics and univariate analysis were performed. We identified 95,123 patients with a total of 251,310 emergency department visits. The annual number of visits increased over the study period, reaching 32,333 in 2019. Men aged 40-60 were the most common demographic group in the cohort (48% of all patients), and men made up a higher proportion of patients in the database (94%) than the VHA population overall (90%). A disproportionate number of visits (32%) came from the top 4.4% of most frequent visitors. Most of the emergency department visits in the database (68%) were associated with medical or psychiatric admission, or interfacility transfer for admission elsewhere. Patients in the cohort accounted for 1.3% of all VHA emergency department visits during the study period, a proportion that is somewhat smaller than what has been reported at non-VHA facilities, despite the high prevalence of addiction disorders in the VHA patient population. We submit that this lower-than-expected proportion of alcohol-related emergency department visits may be due to the access to primary and mental care which is afforded by VHA patient benefits.

Associations Among Race, Ethnicity, and Clinical Profiles of Young Children Evaluated for Autism in the Primary Care Setting

OBJECTIVE

Despite long-standing racial and ethnic disparities in autism spectrum (AS) diagnosis, recent research suggests that overall, greater numbers of Black and Latine children are now diagnosed with AS as compared with non-Latine White (NLW) children in some US regions. However, gaps remain in the equitable detection of Black and Latine children with AS without significant developmental impairment. The objective of this study was to determine whether the clinical profiles of young children evaluated for AS across a statewide system of early autism diagnosis in Indiana vary by race and ethnicity.

METHODS

We examined racial and ethnic differences in: (1) AS symptom severity, (2) developmental functioning, (3) adaptive functioning, and (4) behavior problems in a sample of 147 children, aged 14 to 48 months (M = 2.6 years), referred for AS evaluation.

RESULTS

Clinical profiles of young children evaluated differed significantly by race and ethnicity, with Black and Latine children exhibiting lower developmental (p = 0.008) and adaptive abilities (p = 0.01) and higher AS symptoms (p = 0.03) as compared with NLW children.

CONCLUSION

Potential explanations for findings include racial and ethnic differences in family and community awareness and knowledge about AS and follow-through on evaluation referral, both driven by social determinants of health (SDOH) affecting minoritized children. Bias in screening and assessment instruments and clinician surveillance, screening, and referral practices may also underlie differences in clinical profiles of children evaluated. Future research is needed to understand the SDOH that influence AS detection and diagnosis to improve equitable access to early diagnosis and intervention.

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment

OBJECTIVE

To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion.

STUDY SETTING

Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year.

STUDY DESIGN

Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year.

DATA EXTRACTION METHODS

We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status.

PRINCIPAL FINDINGS

Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states).

CONCLUSIONS

Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Defining the Subtypes of Long COVID and Risk Factors for Prolonged Disease: Population-Based Case-Crossover Study

BACKGROUND

There have been over 772 million confirmed cases of COVID-19 worldwide. A significant portion of these infections will lead to long COVID (post-COVID-19 condition) and its attendant morbidities and costs. Numerous life-altering complications have already been associated with the development of long COVID, including chronic fatigue, brain fog, and dangerous heart rhythms.

OBJECTIVE

We aim to derive an actionable long COVID case definition consisting of significantly increased signs, symptoms, and diagnoses to support pandemic-related clinical, public health, research, and policy initiatives.

METHODS

This research employs a case-crossover population-based study using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) data generated at Veterans Affairs medical centers nationwide between January 1, 2020, and August 18, 2022. In total, 367,148 individuals with ICD-10-CM data both before and after a positive COVID-19 test were selected for analysis. We compared ICD-10-CM codes assigned 1 to 7 months following each patient's positive test with those assigned up to 6 months prior. Further, 350,315 patients had novel codes assigned during this window of time. We defined signs, symptoms, and diagnoses as being associated with long COVID if they had a novel case frequency of ≥1:1000, and they significantly increased in our entire cohort after a positive test. We present odds ratios with CIs for long COVID signs, symptoms, and diagnoses, organized by ICD-10-CM functional groups and medical specialty. We used our definition to assess long COVID risk based on a patient's demographics, Elixhauser score, vaccination status, and COVID-19 disease severity.

RESULTS

We developed a long COVID definition consisting of 323 ICD-10-CM diagnosis codes grouped into 143 ICD-10-CM functional groups that were significantly increased in our 367,148 patient post-COVID-19 population. We defined 17 medical-specialty long COVID subtypes such as cardiology long COVID. Patients who were COVID-19-positive developed signs, symptoms, or diagnoses included in our long COVID definition at a proportion of at least 59.7% (268,320/449,450, based on a denominator of all patients who were COVID-19-positive). The long COVID cohort was 8 years older with more comorbidities (2-year Elixhauser score 7.97 in the patients with long COVID vs 4.21 in the patients with non-long COVID). Patients who had a more severe bout of COVID-19, as judged by their minimum oxygen saturation level, were also more likely to develop long COVID.

CONCLUSIONS

An actionable, data-driven definition of long COVID can help clinicians screen for and diagnose long COVID, allowing identified patients to be admitted into appropriate monitoring and treatment programs. This long COVID definition can also support public health, research, and policy initiatives. Patients with COVID-19 who are older or have low oxygen saturation levels during their bout of COVID-19, or those who have multiple comorbidities should be preferentially watched for the development of long COVID.

Temporary Financial Assistance Reduced The Probability Of Unstable Housing Among Veterans For More Than 1 Year

The Department of Veterans Affairs (VA) aims to reduce homelessness among veterans through programs such as Supportive Services for Veteran Families (SSVF). An important component of SSVF is temporary financial assistance. Previous research has demonstrated the effectiveness of temporary financial assistance in reducing short-term housing instability, but studies have not examined its long-term effect on housing outcomes. Using data from the VA's electronic health record system, we analyzed the effect of temporary financial assistance on veterans' housing instability for three years after entry into SSVF. We extracted housing outcomes from clinical notes, using natural language processing, and compared the probability of unstable housing among veterans who did and did not receive temporary financial assistance. We found that temporary financial assistance rapidly reduced the probability of unstable housing, but the effect attenuated after forty-five days. Our findings suggest that to maintain long-term housing stability for veterans who have exited SSVF, additional interventions may be needed.

Understanding Racial Disparities in Dementia Prevalence Among Veterans

Background

Black and Hispanic older adults have greater incidence of Alzheimer's disease and related dementias relative to White adults, but factors underlying these disparities are not well understood, limiting the ability to address them.

Objective

To determine the impact of demographics, cardiovascular disease (CVD) and risk factors, social determinants of health (SDOH), and neuropsychiatric risk factors on racial/ethnic disparities in dementia risk among Veterans.

Methods

We examined a random sample of 1,579,919 older Veterans (age ≥55) without dementia who received care from the VHA from October 1, 1999 to September 30, 2021. All variables were extracted from national VHA data. We used Cox proportional hazard regression models to examine change in variance in risk of dementia across racial/ethnic groups.

Results

During follow up (mean 11.1 years), 13% of Veterans developed dementia. Relative to White Veterans, the adjusted hazard ratios (AHRs) for developing dementia in sex-adjusted models with age as timescale were 1.65 (95% CI, 1.63-1.67) for Black Veterans and 1.50 (95% CI, 1.44-1.56) for Hispanic Veterans. In the model examining CVD and risk factors, AHRs were 1.53 (95% CI, 1.50-1.55) for Black Veterans and 1.38 (95% CI, 1.33-1.44) for Hispanic Veterans. In the model examining SDOH, AHRs were 1.46 (95% CI, 1.43-1.49) for Black Veterans and 1.34 (95% CI, 1.29-1.40) for Hispanic Veterans.

Conclusions

SDOH and CVD and risk factors accounted for the greatest amount of variance in racial/ethnic disparities in dementia risk. Cardiovascular disease and SDOH are strong possible targets for interventions designed to reduce these disparities.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Importance

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.

Objective

To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.

Design, Setting, and Participants

This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.

Exposures

Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.

Main Outcomes and Measures

The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.

Results

This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.

Conclusions and Relevance

In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Development and validation of a prognostic index for mental health and substance use disorder burden

OBJECTIVE

To develop an accessible index which quantifies MHSUD burden among patients of Veterans Affairs hospitals.

METHOD

We used 21 disorder categories provided by the diagnostic and statistical manual (DSM) to characterize diagnoses among primary care (PC) patients. For each patient, we generated counts of unique disorder categories present during the PC encounter or in the year prior. We used these counts to generate multiple indexes, which we compared in a 60% training sample of our population. Using model fit statistics generated from ordered multinomial logistic regressions, we identified the subset of DSM categories which, structured as index, were most predictive of MHSUD hospitalization and death. We validated and fine-tuned the form of the selected index in the full population using measures of calibration and discrimination.

RESULTS

In model development, the index (I-6) which best fit the data (R2 = 0.191) included the following six disorder categories: substance use, depressive, psychotic, bipolar, trauma, and personality. When applied in the full population and weighted by disorder severity, this index demonstrated good predictive discrimination for MHSUD death (C = 0.66) and hospitalization (C = 0.88) and was well calibrated in comparisons of observed versus predicted outcomes.

CONCLUSIONS

We recommend the I-6 as a parsimonious and effective tool for MHSUD burden risk adjustment.

Rural and Urban Hispanic Patients of the Veterans Health Administration

Hispanic Veterans are the largest growing racial and ethnic minority group in the Veterans Health Administration (VA) system. Though recent research has found increasing suicide rates in this population and a growing rural-urban disparity, literature on core population characteristics remains sparse. We used extensive patient demographic and clinical data from VA's electronic medical record repository to examine geographic and longitudinal variation in Hispanic VA patients from 2001 to 2018. As the first such detailed characterization of this population, this study was largely descriptive in nature, and included heatmaps of Hispanic patient residence across rural and urban US counties, along with descriptive measures of patient characteristics by rurality, and first year of VA use. We found that Hispanic patients (n = 722,893) represented 5.2% of new VA users between 2001 and 2018, a proportion which grew nearly 90% from 4.0% (2001-2006) to 7.5% (2013-2018). Hispanic patients were largely White, male, under age 50, and had minimal illness or disability. The highest prevalence of Hispanic patients was in the Southwest US/Mexico border region, while the Midwest experienced the largest growth of Hispanic patients. Rural Hispanic patients were more likely to be older, male, and to live in areas characterized by small foreign-born populations and high socioeconomic deprivation. Compared with Hispanic patients entering the VA system in 2001-2006, patients in 2013-2018 were younger, more likely to be female, and to live in urban areas. These findings illustrate the wide range of demographic, clinical, and geographic experiences in the growing VA Hispanic population and demonstrate that culturally competent care for Hispanic Veterans must reflect their intra-ethnic diversity.

Epidemiology of Coccidioidomycosis in the Veterans Health Administration, 2013-2022

We describe the epidemiology of coccidioidomycosis among a national cohort of Veterans. Using electronic health record data from adults tested for coccidioidomycosis between 1 January 2013 and 31 December 2022, we analyzed differences in baseline demographics (age, sex, race/ethnicity, birth country, comorbidities, residence, and Charlson Comorbidity Index score) between 4204 coccidioidomycosis-test-positive and 63,322 test-negative Veterans. Log-binomial regression models with adjusted risk ratios (aRRs) were used to evaluate risk factors associated with coccidioidomycosis including dissemination, hospitalization, and mortality. Case counts and incidence rates were highest in select counties in Arizona and California where Coccidioides is endemic. Coccidioidomycosis-positive Veterans were younger, more likely to be male, and Philippine-born. The risk factors most highly associated with being coccidioidomycosis-positive included Native Hawaiian/Pacific Islander (aRR 1.068 [95%CI: 1.039-1.098]), Asian (aRR 1.060 [95%CI: 1.037-1.083]), Black (aRR 1.029 [95%CI: 1.022-1.036]), American Indian/Alaska Native (aRR 1.026 [95%CI: 1.004-1.048]) race, and Hispanic/Latino ethnicity (aRR 1.021 [95%CI: 1.013-1.028]). Black race (aRR: 1.058 [95%CI: 1.037-1.081]) and Hispanic/Latino ethnicity (aRR 1.018 [95%CI: 1.0003-1.036]) were also associated with disseminated coccidioidomycosis, strengthening the evidence for the association of coccidioidomycosis, including severe infections, with specific racial and ethnic groups. There were no statistically significant differences in hospitalization within 45 days of testing or 30-day all-cause mortality. Improving our understanding of coccidioidomycosis risk factors is important for targeted prevention strategies and to reduce delays in diagnosis and ineffective treatment.

Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic

Importance

During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population.

Objective

To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population.

Design, Setting, and Participants

This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023.

Main Outcomes and Measures

Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations.

Results

There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations.

Conclusions and Relevance

In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.

Factors associated with a diagnosis of sarcoidosis among US veterans of Iraq and Afghanistan

This study evaluated risk factors of sarcoidosis among Airborne Hazards and Open Burn Pit Registry (AHOBPR) participants using a retrospective age and sex-matched case-control design of AHOBPR participants deployed to Afghanistan or Southwest Asia with and without sarcoidosis diagnosed in the Veterans Health Administration (VHA). Logistic regression models tested for associations between sarcoidosis and self-reported cumulative deployment-related exposures. 661 Veterans (0.37%) were diagnosed with sarcoidosis in VHA. Logistic regression demonstrated lower odds of sarcoidosis in Hispanic participants (OR 0.08, CI 0.04-0.15) and those who served in the Navy (OR 0.40, CI 0.21-0.72). African American veterans (OR 2.27, CI 1.66-3.11) and former smokers (OR 1.87, CI 1.33-2.62) were at elevated risk. Of the exposure variables, convoy activities had the highest odds of being associated with sarcoidosis and was marginally statistically significant (OR 1.16, CI 1.00-1.35). Sarcoidosis was an uncommon diagnosis among AHOBPR participants and was associated with only one of eight assessed cumulative deployment-related exposures.

Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity.

DATA SOURCES

Administrative data from the Veterans Health Administration's Corporate Data Warehouse.

STUDY DESIGN

We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects.

DATA COLLECTION

We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity.

PRINCIPAL FINDINGS

Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population.

CONCLUSIONS

Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Performance of EHR classifiers for patient eligibility in a clinical trial of precision screening

BACKGROUND

Validated computable eligibility criteria use real-world data and facilitate the conduct of clinical trials. The Genomic Medicine at VA (GenoVA) Study is a pragmatic trial of polygenic risk score testing enrolling patients without known diagnoses of 6 common diseases: atrial fibrillation, coronary artery disease, type 2 diabetes, breast cancer, colorectal cancer, and prostate cancer. We describe the validation of computable disease classifiers as eligibility criteria and their performance in the first 16 months of trial enrollment.

METHODS

We identified well-performing published computable classifiers for the 6 target diseases and validated these in the target population using blinded physician review. If needed, classifiers were refined and then underwent a subsequent round of blinded review until true positive and true negative rates ≥80% were achieved. The optimized classifiers were then implemented as pre-screening exclusion criteria; telephone screens enabled an assessment of their real-world negative predictive value (NPV-RW).

RESULTS

Published classifiers for type 2 diabetes and breast and prostate cancer achieved desired performance in blinded chart review without modification; the classifier for atrial fibrillation required two rounds of refinement before achieving desired performance. Among the 1077 potential participants screened in the first 16 months of enrollment, NPV-RW of the classifiers ranged from 98.4% for coronary artery disease to 99.9% for colorectal cancer. Performance did not differ by gender or race/ethnicity.

CONCLUSIONS

Computable disease classifiers can serve as efficient and accurate pre-screening classifiers for clinical trials, although performance will depend on the trial objectives and diseases under study.

Examination of increasing suicide rates among rural Hispanic VA patients

PURPOSE

Death by suicide is increasing more rapidly among Hispanics than non-Hispanics who use United States Department of Veterans Affairs (VA) health services, and the increase is most rapid among those living in rural areas. Our goal was to identify characteristics of rural Hispanic VA patients that contribute to this emerging disparity.

METHODS

We linked electronic medical records from the VA, personnel data from the US Department of Defense, mortality data from the US National Death Index, and data on area characteristics from the US Census Bureau to examine suicide trends among Hispanic VA patients from 2005 through 2019. After identifying the strongest predictors of suicide in the rural and urban Hispanic populations, we examined how those characteristics changed over time.

FINDINGS

Age and sex-adjusted suicide mortality rates were consistently higher for rural versus urban Hispanic patients beginning in 2012, with the most recent rolling 5-year average rates being 31.0 per 100,000 for rural compared to 20.3 per 100,000 for urban in 2019. Models to predict suicide had fair performance in the rural (accuracy = 0.62, 95% CI: 0.51, 0.73) and urban (accuracy = 0.67, 95% CI: 0.63, 0.70) groups. Mental health diagnoses were predictive of suicide among rural Hispanic patients, but there was no evidence that mental health diagnoses were increasing more rapidly in rural compared to urban patients.

CONCLUSIONS

While we confirmed that there is a higher rate of death by suicide among rural Hispanic VA patients relative to their urban counterparts, we were unable to identify clear drivers of this finding.

Evaluating policies to improve access to mental health services in rural areas

PURPOSE

The United States Department of Veterans Affairs (VA) has gradually implemented policies to increase access to mental health care outside of VA medical centers. Most notably, this included requirements to offer mental health services at VA-administered community-based clinics in 2008 and increased access to VA-paid care in the community beginning in 2014. Our objective was to understand how mental health service use patterns changed for rural VA patients during this time.

METHODS

We developed a longitudinal cohort of all rural patients who used VA services between 2002 and 2019 (N = 3,345,862). We examined individual, health care, and contextual predictors of mental health service use as well as modalities of mental health service use during policy-relevant time periods using descriptive statistics.

FINDINGS

Access to mental health services increased with each policy change. The annual percentage of rural VA patients accessing mental health services increased from 11.4% in the earliest years (2002-2004) to 19.8% in the latest years (2017-2019). The most rapid period of increase followed a requirement for availability of mental health services at VA-administered community clinics. Increasing access to VA-paid care in the community had less effect. By the end of the evaluation, gaps remained in the delivery of care to elderly patients over the age of 75.

CONCLUSIONS

Rural patients use mental health services when they become available. Access was the highest with a combination of changes to both delivery modalities and payment methods. Continued, and perhaps different efforts are required to address a persistent disparity for older patients.