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

Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations

Background

Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation.

Objective

This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA).

Methods

The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined.

Results

Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation.

Conclusion

We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

Causes of Death of Transgender and Gender Diverse Veterans

INTRODUCTION

Transgender and gender diverse (TGD) veterans face numerous challenges due to stigma and marginalization, which have a significant impact on their health and well-being. However, there is insufficient data on cause-specific mortality in TGD veteran populations in the U.S. The purpose of this study was to describe the leading causes of death in a sample of TGD veterans who received care from the Veterans Health Administration.

METHODS

A secondary data analysis was conducted using Veterans Health Administration electronic health record data matched with death certificate records from the National Death Index from October 1, 1999 to December 31, 2019. Using record axis codes from National Death Index data, the 25 most frequent underlying and all causes of death were summarized.

RESULTS

Deaths occurred in 1,415 TGD veterans. Ranking by any mention on the death certificate, mental and behavioral disorders due to psychoactive substance use (17.2%), conduction disorders and cardiac dysrhythmias (15.3%), chronic obstructive pulmonary disease (15.1%), diabetes mellitus (13.9%), and chronic ischemic heart disease (13.3%) were the top five causes of death. Three distinct methods of suicide appeared as the 7th (firearms), 17th (self-poisoning), and 24th (hanging) underlying causes of death for TGD veterans.

CONCLUSIONS

Targeted prevention efforts or interventions to reduce the frequency and severity of causes of death, particularly mental and behavioral health disorders and metabolic disorders, could prevent premature mortality among TGD adults.

An Open-Label Pilot Study Investigating Noninvasive High-Frequency Peripheral Nerve Fiber Stimulation in Chronic Pain

OBJECTIVE

Providing sustained and effective treatment via the peripheral nervous system for the management of chronic pain is challenging. Application of noninvasive high-frequency stimulation at or near the painful area may benefit those with chronic pain. This open-label pilot survey examined the impact of this stimulation on pain intensity, activities of daily living, functional capacity, and medication consumption after 2 weeks of treatment.

METHODS

Stimulation was administered at home using the summation of two high-frequency sinusoidal alternating signals at 3858 and 3980 Hz delivered between two electrodes placed directly over one or two locations of pain. Individuals completed a survey after 2 weeks to assess pain, activities of daily living (ADL), pain medication consumption, quality of life (QoL), mood, sleep, functional outcomes, and satisfaction.

RESULTS

463 individuals (372 males; 91 females) retuned the completed survey after 2 weeks of treatment. Pain and ADL scores significantly improved at follow-up compared with baseline (pain mean difference: 3.05; 95% confidence interval [CI]: 2.86, 3.24; ADL mean difference: 1.82; 95% CI: 1.60, 2.04). Corresponding improvements in QoL, sleep, mood, functional outcomes, and satisfaction were noted. On average, 8.00 ± 11.11 hours of pain relief were reported with 54% experiencing reductions in pain medication consumption. 98% would use the stimulation in the future.

CONCLUSION

Two weeks of noninvasive high-frequency peripheral nerve fiber stimulation appeared to confer positive effects in individuals with chronic pain. Future research employing a control group/arm is needed to establish the long-term impact of this bioelectric technique in specific pain cohorts.

Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease

BACKGROUND

It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA.

METHODS

The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup.

RESULTS

Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast.

CONCLUSIONS

In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.

Health considerations for transgender women and remaining unknowns: a narrative review

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

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.

Trends in hysterectomy rates among women veterans in the US Department of Veterans Affairs

BACKGROUND

Prior studies demonstrate a higher prevalence of hysterectomy among veterans compared with nonveterans. While studies identify overall decreasing hysterectomy rates in the United States, none report rates of hysterectomy among women veterans. Given the increasing numbers of women veterans using Veterans Affairs health care, there is an ongoing need to ensure high-quality gynecology care. Therefore, it is important to examine current hysterectomy trends, including proportion of minimally invasive surgeries, among veterans using Veterans Affairs health care.

OBJECTIVE

Our objective was to describe hysterectomy trends and utilization of minimally invasive hysterectomy in the Veterans Affairs healthcare system.

STUDY DESIGN

This longitudinal study used Veterans Affairs clinical and administrative data from fiscal year 2008 to 2014 to identify hysterectomies provided or paid for by Veterans Affairs. Crude and age-adjusted hysterectomy rates were calculated by indication (benign or malignant), mode (abdominal, laparoscopic, vaginal, robotic assisted, unspecified), and source of care (provided vs paid for by Veterans Affairs). Mode and indication for hysterectomy were classified using International Classification of Diseases, ninth revision, codes. The distribution of hysterectomy mode in each year was calculated by indication and source of care.

RESULTS

Between fiscal year 2008 and fiscal year 2014, the total hysterectomy rate decreased from 4.0 per 1000 to 2.6 per 1000 unique women veteran Veterans Affairs users. Age-adjusted rates of abdominal hysterectomy for benign indications decreased over the study period from 1.54 per 1000 (95% confidence interval, 1.40-1.69) to 0.77 per 1000 (95% confidence interval, 0.69-0.85) for procedures provided by Veterans Affairs and 0.77 per 1,000 (95% confidence interval, 0.69-0.85) to 0.29 per 1,000 (95% confidence interval, 0.23-0.34) for those paid for by Veterans Affairs. Among hysterectomies for benign indications provided by (n = 5296) or paid for (n = 2610) by Veterans Affairs, the percentage of hysterectomies performed abdominally decreased from 67.2% to 46.8% and from 68.9% to 57.6%, respectively.

CONCLUSION

These findings suggest that gynecology care provided within Veterans Affairs has kept pace with national trends in reducing hysterectomy rates and increasing utilization of minimally invasive surgical techniques.

Transgender Veterans' Satisfaction With Care and Unmet Health Needs

BACKGROUND

Transgender individuals are overrepresented among Veterans. However, little is known regarding their satisfaction with Veterans Administration (VA) care and unmet health needs.

OBJECTIVES

This study examined transgender Veterans' satisfaction with VA medical and mental health care, prevalence of delaying care, and correlates of these outcomes.

RESEARCH DESIGN

We used data from transgender Veterans collected in 2014 through an online, national survey.

SUBJECTS

In total, 298 transgender Veterans living in the United States.

MEASURES

We assessed patient satisfaction with VA medical and mental health care and self-reported delays in seeking medical and mental health care in the past year. Potential correlates associated with these 4 outcomes included demographic, health, and health care variables.

RESULTS

Over half of the sample used VA (56%) since their military discharge. Among transgender Veterans who had used VA, 79% were satisfied with medical care and 69% with mental health care. Lower income was associated with dissatisfaction with VA medical care, and being a transgender man was associated with dissatisfaction with VA mental health care. A substantial proportion reported delays in seeking medical (46%) or mental (38%) health care in the past year (not specific to VA). Screening positive for depression and/or posttraumatic stress disorder was associated with delays in seeking both types of care.

CONCLUSIONS

Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Further, many report delaying accessing care, particularly those with depression and/or posttraumatic stress disorder symptoms. Adapting health care settings to better engage these vulnerable Veterans may be necessary.

Mortality Among Veterans with Transgender-Related Diagnoses in the Veterans Health Administration, FY2000-2009

PURPOSE

The aims of this project were to document all-cause and suicide mortality among Veteran Healthcare Administration (VHA) utilizers with The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis consistent with transgender status.

METHODS

The study population consisted of VHA patients identified as having any one of four diagnosis codes indicating transgender status (n=5,117) gathered from the VA National Patient Care Database. Mortality data were gathered from the National Death Index from 2000-2009 for 1,277 veterans with transgender-related ICD-9-CM diagnoses. The remaining 3,840 were not searched because they had VHA utilization after 2009 (indicating they were alive). Person-time at risk (person-years) for crude rates were calculated based on the time from an individual's index diagnosis to either death or the end of FY 2009. Causes of death were categorized using ICD-10 code groups.

RESULTS

Approximately 9.3% (n=309) veterans with transgender-related ICD-9-CM diagnoses died across the study period. Although diseases of the circulatory system and neoplasms were the first and second leading causes of death, respectively, the other ranked causes of mortality differed somewhat from patterns for the US during the same time span. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses across the 10-year period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for other serious mental illness in VHA (e.g., depression, schizophrenia). The average age of suicide decedents was 49.4 years.

CONCLUSION

The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses is higher than in the general population, and they may be dying by suicide at younger ages than their veteran peers without transgender-related ICD-9-CM diagnoses. Future research, such as age-adjusted rates or accounting for psychiatric co-morbidities, will help to better clarify if the all-cause and suicide mortality rates are elevated for veterans with transgender-related ICD-9-CM diagnoses.

Reproductive health diagnoses of women veterans using department of Veterans Affairs health care

BACKGROUND

Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care.

OBJECTIVE

To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses.

RESEARCH DESIGN

This study is a cross-sectional analysis of VA administrative and clinical data.

SUBJECTS

The study included women Veterans using VA health care in FY10.

MEASURES

Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, ≥65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis.

RESULTS

The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged ≥65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001).

CONCLUSIONS

Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.

Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative

BACKGROUND

Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients.

OBJECTIVE

To evaluate early implementation of this national policy.

METHODS

At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data.

RESULTS

Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001).

CONCLUSIONS

VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.

Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing veterans health administration care

OBJECTIVES

We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis.

METHODS

We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk.

RESULTS

GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population.

CONCLUSIONS

The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Rural women veterans demographic report: defining VA users' health and health care access in rural areas

PURPOSE

While many women choose to live in rural areas after retiring from active military duty, a paucity of studies examine rural women veterans' health care needs. This report is the first of its kind to describe the population demographics and health care utilization of rural female veteran patients enrolled in the Department of Veterans Affairs (VA).

METHODS

Using the National Patient Care Datasets (n = 327,785), we ran adjusted regression analyses to examine service utilization between (1) urban and rural and (2) urban and highly rural women veterans.

FINDINGS

Rural and highly rural women veterans were older and more likely to be married than their urban counterparts. Diagnostic rates were generally similar between groups for several mental health disorders, hypertension, and diabetes, with the exception of nonposttraumatic stress anxiety that was significantly lower for highly rural women veterans. Rural and highly rural women veterans were less likely to present to the VA for women's specific care than urban women veterans; highly rural women veterans were less likely to present for mental health care compared to urban women veterans. Among the users of primary care, mental health, women's specific, and all outpatient services, patients' annual utilization rates were similar.

CONCLUSIONS

Improved service options for women's specific care and mental health visits may help rural women veterans access care. Telehealth technologies and increased outreach, perhaps peer-based, should be considered. Other recommendations for VA policy and planning include increasing caregiver support options, providing consistency for mental health services, and revising medical encounter coding procedures.

Trends in rates and attributable costs of conditions among female VA patients, 2000 and 2008

RESEARCH OBJECTIVE

We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.

METHODS

Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.

RESULTS

The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.

CONCLUSION

Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.

Health indicators for military, veteran, and civilian women

BACKGROUND

Women who have served in the military are a rapidly growing population. No previous studies have compared directly their health status to that of civilians.

PURPOSE

To provide estimates of several leading U.S. health indicators by military service status among women.

METHODS

Data were obtained from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. Health outcomes were compared by military status using multivariable logistic regression among the female participants (274,399 civilians, 4221 veterans, 661 active duty, and 995 National Guard or Reserves [NG/R]). Data were analyzed in August 2011.

RESULTS

Veterans reported poorer general health and greater incidence of health risk behaviors, mental health conditions, and chronic health conditions than civilian women. Active duty women reported better access to health care, better physical health, less engagement in health risk behaviors, and greater likelihood of having had a recent Pap than civilian women. Women from the NG/R were comparable to civilians across most health domains, although they had a greater likelihood of being overweight or obese and reporting a depressive and anxiety disorder.

CONCLUSIONS

Compared with civilian women, NG/R women rated their health and access to health care similarly and active duty women rated theirs better on several domains, but veterans consistently reported poorer health.

Using research to transform care for women veterans: advancing the research agenda and enhancing research-clinical partnerships

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health.

Initiation of Primary Care-Mental Health Integration programs in the VA Health System: associations with psychiatric diagnoses in primary care

BACKGROUND

Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program.

OBJECTIVES

To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment.

RESEARCH DESIGN

Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white.

CONCLUSIONS

Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

Trauma history and risk of the irritable bowel syndrome in women veterans

BACKGROUND

Over 1.8 million women in the U.S. are veterans of the armed services. They are at increased risk of occupational traumas, including military sexual trauma.

AIM

To evaluate the association between major traumas and irritable bowel syndrome among women veterans accessing Veteran Affairs (VA) healthcare.

METHODS

We administered questionnaires to assess trauma history as well as IBS, post-traumatic stress disorder (PTSD) and depression symptoms to 337 women veterans seen for primary care at VA Women's Clinic between 2006 and 2007. Logistic regression was used to evaluate the association between individual traumas and IBS risk after adjustment for age, ethnicity, PTSD and depression.

RESULTS

Irritable bowel syndrome prevalence was 33.5%. The most frequently reported trauma was sexual assault (38.9%). Seventeen of eighteen traumas were associated with increased IBS risk after adjusting for age, ethnicity, PTSD and depression, with six statistically significant [range of adjusted odds ratios (OR) between 1.85 (95% CI, 1.08-3.16) and 2.6 (95% CI, 1.28-3.67)]. Depression and PTSD were significantly more common in IBS cases than controls, but neither substantially explained the association between trauma and increased IBS risk.

CONCLUSIONS

Women veterans report high frequency of physical and sexual traumas. A lifetime history of a broad range of traumas is independently associated with an elevated risk of the irritable bowel syndrome.

Gender differences in veterans health administration mental health service use: effects of age and psychiatric diagnosis

PURPOSE

The objective of this study was to compare gender differences in mental health disease burden and outpatient mental health utilization among veterans utilizing Veterans Health Administration (VHA) mental health services in fiscal year 1999 (FY99), after the first Gulf War and significant restructuring of VHA services.

METHODS

We used logistic regression to examine the relationships among gender, age, diagnostic groups, and utilization of mental health and specialty mental health services in a national sample of veterans. The sample included 782,789 veterans with at least 1 outpatient visit in the VHA in FY99 associated with a mental health or substance abuse (SA) diagnosis. Subgroup analyses were performed for 4 diagnostic categories: 1) posttraumatic stress disorder (PTSD), 2) SA disorders, 3) bipolar and psychotic disorders, and 4) mood and anxiety disorders.

MAIN FINDINGS

Younger women veterans (<35 years old) were significantly less likely and older women (> or =35) more likely to use any mental health services in comparison with their male counterparts. Similar findings were observed for younger women diagnosed with SA or mood and anxiety disorders, but not among veterans with PTSD or bipolar and psychotic disorders, among whom no there were no gender or age differences. In the case of specialized services for SA or PTSD, women younger than 55 with SA or PTSD were significantly less likely to use services than men.

CONCLUSION

Women veterans underutilized specialty mental health services in relation to men but receipt of mental health care overall in FY99 varied by age and diagnosis. Examining gender differences alone, without taking other factors into account, may not provide an adequate picture of women veterans' current mental health service needs.