Incident Musculoskeletal Conditions Among Men and Women Veterans Returning From Deployment

An Update on the Healthy Soldier Effect in U.S. Veterans

INTRODUCTION

The healthy soldier effect (HSE) describes a phenomenon of enduring health and lower mortality among veterans due in part to initial screening procedures and health care access. Although early data were supportive of a broad HSE among former military members, more recent investigations have suggested a possible attenuation of the effect with older age. The present study aimed to provide an update of the HSE using an expansive Veterans Health Administration (VHA)-wide sample with a particular focus on age and sex effects.

MATERIALS AND METHODS

Mortality data for veterans within the VHA were obtained from the VHA Support Service Center program office and compared to mortality data from the general U.S. population spanning FY2014 to the second quarter of FY2020. The standardized mortality ratio (SMR) was calculated for the overall sample and for age- and sex-specific cohorts. Mortality rate ratios were also calculated and compared across sexes.

RESULTS

Lower SMRs were observed in veterans compared to the general U.S. population (SMR 0.866). This effect was most prominent in younger and very old veterans, although a higher mortality was seen in the 55- to 64-year age cohort (SMR 1.371 for males and 1.074 for females). The HSE in females was lower than that in males in the <55-year age group but became higher in older cohorts.

CONCLUSIONS

This is the largest investigation to date examining the HSE in U.S. veterans and includes younger veterans from more recent military eras. Higher mortality among the 55- to 74-year age groups merits further investigation, as does the relatively higher mortality among older female veterans. Our findings have implications for the provision of health care and preventative care to these veterans most at risk for higher mortality.

Physical health of Post-9/11 U.S. Military veterans in the context of Healthy People 2020 targeted topic areas: Results from the Comparative Health Assessment Interview Research Study

Large-scale epidemiological studies suggest that veterans may have poorer physical health than nonveterans, but this has been largely unexamined in post-9/11 veterans despite research indicating their high levels of disability and healthcare utilization. Additionally, little investigation has been conducted on sex-based differences and interactions by veteran status. Notably, few studies have explored veteran physical health in relation to national health guidelines. Self-reported, weighted data were analyzed on post-9/11 U.S. veterans and nonveterans (n = 19,693; 6,992 women, 12,701 men; 15,160 veterans, 4,533 nonveterans). Prevalence was estimated for 24 physical health conditions classified by Healthy People 2020 targeted topic areas. Associations between physical health outcomes and veteran status were evaluated using bivariable and multivariable analyses. Back/neck pain was most reported by veterans (49.3 %), twice that of nonveterans (22.8 %)(p < 0.001). Adjusted odds ratios (AORs) for musculoskeletal and hearing disorders, traumatic brain injury, and chronic fatigue syndrome (CFS) were 3-6 times higher in veterans versus nonveterans (p < 0.001). Women versus men had the greatest adjusted odds for bladder infections (males:females, AOR = 0.08, 95 % CI:0.04-0.18)(p < 0.001), and greater odds than men for multiple sclerosis, CFS, cancer, irritable bowel syndrome/colitis, respiratory disease, some musculoskeletal disorders, and vision loss (p < 0.05). Cardiovascular-related conditions were most prominent for men (p < 0.001). Veteran status by sex interactions were found for obesity (p < 0.03; greater for male veterans) and migraine (p < 0.01; greater for females). Healthy People 2020 targeted topic areas exclude some important physical health conditions that are associated with being a veteran. National health guidelines for Americans should provide greater consideration of veterans in their design.

A Pilot Study Comparing Two Measures of Perceived Health Services Access Among Military Veterans With Musculoskeletal Injuries and Mental Health Conditions

INTRODUCTION

Service members endure a number of musculoskeletal injuries (MSIs) during service (e.g., ankle sprains and chronic back pain). Musculoskeletal injuries can reduce engagement in physical activity after military service and contribute to a sedentary lifestyle that diminishes physical health and elevates the risk for psychological distress including suicide-related behaviors. Yet, little is known about barriers and facilitators to accessing care in veterans with co-occurring MSI and mental health conditions. The purpose of this study was to pilot two brief measures of barriers and facilitators to rehabilitation and mental health services in military veterans with musculoskeletal and mental health conditions. Self-report tools vary in their response formats in ways that can impact usability, data quality, and completeness. We examine two response styles (i.e., checklist vs. thermometer) for two health services (mental health and rehabilitation) to determine usability, patterns in item endorsement, and veteran preference.

MATERIALS AND METHODS

Barriers and facilitators informed by the Fortney Veterans Healthcare Access model were assessed by veterans (n = 31) on the newly developed 22-item, paper-and-pencil scale with separate ratings for mental health and rehabilitation services. All participants completed scales with both response styles and the order of administration was randomized (i.e., either the checklist first or the thermometer-style response first). Data also included self-reported demographics, musculoskeletal and mental health diagnoses, health-related quality of life, physical activity levels, mental health symptoms, suicide risk, and coronavirus disease of 2019 pandemic-related stress.

RESULTS

Veterans reported no differences in ease of use across response formats; however, 83.9% (n = 26) preferred the checklist style, with only 3.22% (n = 1) preferring the thermometer format. Checklist items also resulted in less missing data (i.e., range 0.00%-6.45%) than the thermometer-style option (i.e., range 6.45%-61.30%). On the checklist, total number of perceived barriers was low for mental health and rehabilitation services (i.e., M = 1.58 and M = 1.61, respectively). Distance to care and problems related to symptoms were the most frequently identified barriers for both services. Facilitators outnumbered barriers for mental and rehabilitation services, and nearness of the clinic/hospital was the top-rated facilitator for both. On the thermometer, the perceived strength of each mental health (M = 39.37) and rehabilitation (M = 39.81) service barrier was moderate (0-100 scale), while the average perceived strength of each mental health (M = 61.66) and rehabilitation service (M = 61.84) facilitator was higher. Associations between barrier and facilitator scores with mental and physical health indicators were small with exceptions. For instance, suicide attempt likelihood was positively correlated with rehabilitation services barriers; mental health burden was positively associated with both barriers and facilitators.

CONCLUSIONS

Results of this pilot comparing two measurement approaches identified actionable next steps. Brief barriers and facilitators checklists were viable for veteran ratings across type of health. The thermometer-based tool captured the perceived strength of barriers and facilitators but yielded problematic rates of missing data in its current form and was not preferred by veterans.

Risk factors associated with healthcare utilization for spine pain

OBJECTIVE

This study examined potential risk factors associated with healthcare utilization among patients with spine (i.e., neck and back) pain.

METHODS

A two-stage sampling approach examined spine pain episodes of care among veterans with a yearly outpatient visit for six consecutive years. Descriptive and bivariate statistics, followed by logistic regression analyses, examined baseline characteristics of veterans with new episodes of care who either continued or discontinued spine pain care. A multivariable logistic regression model examined correlates associated with seeking continued spine pain care.

RESULTS

Among 331,908 veterans without spine pain episodes of care during the two-year baseline observation period, 16.5% (n = 54,852) had a new episode of care during the following two-year observation period. Of those 54,852 veterans, 37,025 had an outpatient visit data during the final two-year follow-up period, with 53.7% (n = 19,865) evidencing continued spine pain care. Those with continued care were more likely to be overweight or obese, non-smokers, Army veterans, have higher education, and had higher rates of diagnoses of all medical and mental health conditions examined at baseline. Among several important findings, women had 13% lower odds of continued care during the final two-year observation period, OR 0.87 (0.81, 0.95).

CONCLUSIONS

A number of important demographics and clinical correlates were associated with increased likelihood of seeking new and continued episodes of care for spine pain; however, further examination of risk factors associated with healthcare utilization for spine pain is indicated.

Satisfaction of the Use of Telehealth and Access to Care for Veterans During the COVID-19 Pandemic

Background: While many health care providers have shifted toward telehealth services in response to the COVID-19 pandemic, little is known about the perception and acceptance of such services, particularly among vulnerable populations. Veterans, who are at increased risk of physical and mental health needs, may benefit from the use and availability of telehealth services. Materials and Methods: Cross sectional survey data related to telehealth use, satisfaction, and access were collected through an online survey. Participants from previous research studies and veterans receiving care at a national veteran behavioral health organization were invited to participate. Results: A total of 404 veterans participated. Before the pandemic, many veterans had never used telehealth for physical (72%) or mental (76%) health care. Since the start of the pandemic, 62% of participants reported they received some care through telehealth services. Most participants found telehealth valuable and helpful (82%), indicated the technology was well explained (77%), and felt that issues were resolved quickly and easily (67%). Access to care was limited among participants who utilize massage therapy (64%), dental care (53%), routine checkups (50%), acupuncture (50%), and physical therapy (48%). Discussion: These findings showed an increase in the use of telehealth services and overwhelming satisfaction among veterans. Despite this, some veterans indicated barriers to receiving physical and mental health care. Conclusions: This provides an opportunity to expand the use of telehealth services to meet the health care needs of veterans. Barriers to care should be addressed to minimize the impact on the well-being of veterans.

Musculoskeletal Injuries in US Air Force Security Forces, January 2009 to December 2018

OBJECTIVE

To determine the incidence, types, and risk factors of musculoskeletal injuries in a military security forces population.

METHODS

Demographic and diagnostic data were retrieved on enlisted US Air Force security forces personnel who served on active duty between January 2009 and December 2018. Incidence rates and ratios were calculated using Poisson regression.

RESULTS

During 251,787 person-years of exposure, 62,489 personnel served on active duty. Of these, 40,771 (65.2%) were diagnosed with at least one musculoskeletal injury. The majority (60.1%) of the 164,078 unique musculoskeletal injuries were inflammation and pain secondary to overuse. After adjusting for other factors, women had a 31% higher injury rate than men, and those who were overweight and obese had 15% and 30% higher rates, respectively, than normal-weight peers.

CONCLUSIONS

Modifiable and non-modifiable factors contribute to musculoskeletal injuries in the security forces career field.