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Gil A, Schuman D, Chang KY, Liu Z, Hwang CL. Implications of Physical Activity in Reducing Alcohol Use for Women Veterans: A Narrative Review. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:554-564. [PMID: 39035145 PMCID: PMC11257116 DOI: 10.1089/whr.2023.0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 07/23/2024]
Abstract
Women veterans (WV) are a fast-growing population in the United States with concerning health disparities. Reports of increased risks of cardiovascular disease (CVD) and poorer health are evident in WV compared with their civilian counterparts. The transition from active duty to veteran poses additional life stressors, causing changes in health behaviors such as unhealthy alcohol consumption and decreased physical activity, which may explain health disparities in WV. The changes in these two health risk behaviors may be influenced by each other, and emerging evidence suggests that physical activity aids in managing alcohol consumption during alcohol use treatment. In this general narrative review, we summarized findings from studies involving WV on (1) the associations between alcohol consumption and physical activity and (2) the effect of physical activity on reducing alcohol use. We also discussed the clinical consideration of adding physical activity to alcohol use interventions for WV. Most of the literature included in this review has been based on predominantly veteran men populations. This knowledge gap highlights the importance of continued efforts and research studies targeting WV to eliminate health disparities among them.
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Affiliation(s)
- Alfredo Gil
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, USA
| | - Donna Schuman
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
| | - Keng-Yu Chang
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, USA
| | - Zhaoli Liu
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Chueh-Lung Hwang
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, USA
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Pebole MM, Whitworth JW, Iverson KM, Currao A, Fortier CB. Traumatic Brain Injury and Posttraumatic Stress Disorder Are Associated with Physical Health Burden among Post-9/11 Women Veterans. J Womens Health (Larchmt) 2024. [PMID: 38873776 DOI: 10.1089/jwh.2024.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
Background: Little research focuses on physical health outcomes of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) among post-9/11 women veterans (WVs). This study examined lifetime TBI, current PTSD, and their associations with biomarkers of cardiometabolic health, sleep, pain, and functional disability among post-9/11 WVs. Methods: WVs (n = 90) from the Translational Research Center for TBI and Stress Disorders longitudinal cohort study were included in this study. Gold standard clinician administered interviews assessed lifetime TBI (Boston Assessment of TBI-Lifetime) and current PTSD symptoms (Clinician-Administered PTSD Scale-IV). Objective measures of health included waist-hip ratio (WHR) and fasted blood biomarker (high density lipoprotein [HDL], low density lipoprotein [LDL], blood glucose, triglycerides) levels. Self-reported surveys assessed sleep, pain, and functional disability. Results: Just under two-thirds (58.9%) of WVs experienced a lifetime TBI, and just over half (53.3%) of this sample had a current PTSD diagnosis at the time of testing. Lifetime TBI was significantly associated with higher WHR, triglycerides levels, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.01 to 1.12). Current PTSD was significantly associated with higher WHR, lower HDL, and worse pain and sleep (ps = <0.01 to 0.02; ds = 0.009 to 1.19). PTSD was significantly associated with lower total functioning and each of its subdomains (βs = -0.58 to 0.63; ps = <0.001 to 0.02). Lifetime TBI was significantly associated with total functioning, mobility, and life/work (βs = -0.20 to 0.30; ps = <0.01 to 0.02). Conclusions: These findings highlight the importance of screening for lifetime TBI and cardiovascular disease for WVs and support transdiagnostic treatment approaches targeting physical health outcomes.
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Affiliation(s)
- Michelle M Pebole
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - James W Whitworth
- National Center for PTSD Behavioral Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Massachusetts, USA
| | - Katherine M Iverson
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston Massachusetts, USA
- National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Alyssa Currao
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Catherine B Fortier
- The Translational Research Center for TBI and Stress Disorders (TRACTS), Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Inderstrodt J, Stryczek KC, Vargas SE, Crawford JN, Hooker T, Kroll-Desrosiers AR, Marteeny V, Wallace KF, Mattocks K. Facilitators and Barriers to Breastfeeding Among Veterans Using Veterans Affairs Maternity Care Benefits. Womens Health Issues 2024; 34:309-316. [PMID: 38326149 DOI: 10.1016/j.whi.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION U.S. veterans of childbearing age represent one of the fastest growing populations using Veterans Affairs (VA) health care. The VA does not provide obstetric care directly but pays for VA-enrolled veterans to obtain outside obstetric care. The VA also provides maternity care coordination (MCC) services, including lactation support. Breastfeeding benefits mothers and babies; however, previous research shows that veteran mothers quit exclusive breastfeeding earlier than the American Academy of Pediatrics and World Health Organization recommendation of 6 months. This study aimed to understand facilitators and barriers to breastfeeding among a cohort of veterans who used VA maternity care benefits. METHODS Qualitative data from an open-ended question from a national sample of postpartum veterans using VA pregnancy benefits were coded using deductive and inductive content analysis within a matrix framework. Quantitative data were used to contextualize the responses. RESULTS Four themes emerged from the data: (1) impacts on health of baby/mother; (2) the ability to breastfeed; (3) early postnatal experiences breastfeeding; and (4) cost/convenience. Among those who responded to the open-ended breastfeeding question (329/669), most participants (n = 316; 96%) attempted breastfeeding their current baby. Respondents who did not initiate breastfeeding or who discontinued breastfeeding earlier than planned cited diverse reasons. These included low milk supply, poor latch, nipple pain, mental health factors, and low confidence in their ability to continue breastfeeding. Participants cited the MCC program as a facilitator to breastfeeding, and non-VA hospital experiences were mentioned as barriers. CONCLUSION Veterans in this cohort of 329 veterans who responded to an open-ended breastfeeding question wanted and attempted to breastfeed; however, barriers such as lactation challenges and unsupportive health care providers made it difficult to continue the practice. As the MCC program grows to include more lactation professionals, MCCs may address barriers such as lactation challenges and unsupportive non-VA health care providers. Further program development should focus on addressing these challenges prenatally.
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Affiliation(s)
- Jill Inderstrodt
- Indiana University Fairbanks School of Public Health, Indianapolis, Indiana.
| | | | - Sara E Vargas
- Miriam Hospital & Brown University Medical School, Providence, Rhode Island
| | - Jennifer N Crawford
- Albuquerque VA Medical Center, Albuquerque, New Mexico; University of New Mexico, Albuquerque, New Mexico
| | - Taylor Hooker
- Office of Health Equity, Veterans Health Administration, Washington, District of Columbia
| | - Aimee R Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Valerie Marteeny
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Kate F Wallace
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; University of Massachusetts Chan Medical School, Worcester, Massachusetts
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Yarish NM, Posis AIB, Nguyen S, Weitlauf J, Bellettiere J, Saquib N, Richey PA, Allison M, Kroenke C, Goveas JS, Coday M, LaCroix AZ. Loneliness, social isolation, and cardiovascular disease among nonveteran and veteran women. J Women Aging 2024:1-12. [PMID: 38659158 DOI: 10.1080/08952841.2024.2336655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
We examined the prospective associations of social isolation and loneliness with incident cardiovascular disease (CVD) among aging nonveteran and veteran women, and effect modification by veteran status. Participants with no history of myocardial infarction (MI), stroke, coronary heart disease (CHD), or coronary heart failure from the Women's Health Initiative Extension Study II self-reported social isolation, loneliness, health behaviors, health status, and veteran status. CVD and CVD subevents were physician adjudicated. Hazard ratios (HR) and 95% confidence intervals (CI) for the Interquartile Range (IQR) in social isolation (IQR = 1) and loneliness (IQR=.33) were calculated using Cox proportional hazard models adjusting for sociodemographic, health behavior, and health status characteristics. Veteran status was tested as an effect modifier. Among 52,442 women (Mean age = 79 ± 6.1; veterans n = 1023; 89.2% non-Hispanic White), 3579 major CVD events occurred over an average 5.8 follow-up years. Compared to nonveterans, veteran women reported higher levels of social isolation (p < .01) and loneliness (p < .01). The CVD HR was 1.07 (95% CI, 1.04-1.10) for the IQR in social isolation and 1.03 (95% CI, 1.10-1.06) for the IQR in loneliness. The HR for the IQR in both social isolation and loneliness was 1.10 (95% CI, 1.05-1.15). Social isolation was associated with CHD (HR = 1.12; 95% CI, 1.03-1.21). The CHD HR for the IQR in social isolation was 1.12 (95% CI, 1.03-1.21). Associations did not differ by veteran status (all p-interactions > 0.08). Findings suggest that the adverse associations of social isolation and loneliness with CVD are similar among veteran and nonveteran women.
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Affiliation(s)
- Natalie M Yarish
- School of Community and Environmental Health, Old Dominion University, Norfolk, Virginia, USA
| | - Alexander Ivan B Posis
- Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego, San Diego, California, USA
- School of Public Health, San Diego State University, San Diego, California, USA
| | - Steve Nguyen
- Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego, San Diego, California, USA
| | - Julie Weitlauf
- Veterans Affairs Palo Alto Health Care System, Livermore, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - John Bellettiere
- Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego, San Diego, California, USA
| | - Nazmus Saquib
- Sulaiman Al Rajhi University, Al Bukayriyah, Saudi Arabia
| | - Phyllis A Richey
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Matthew Allison
- Division of Preventive Medicine, Department of Family Medicine, UC San Diego, San Diego, California, USA
| | - Candyce Kroenke
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Mace Coday
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Andrea Z LaCroix
- Herbert Wertheim School of Public Health and Human Longevity Science, UC San Diego, San Diego, California, USA
- Women's Health Initiative, USA
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Ebrahimi R, Dennis PA, Alvarez CA, Shroyer AL, Beckham JC, Sumner JA. Posttraumatic Stress Disorder Is Associated With Elevated Risk of Incident Stroke and Transient Ischemic Attack in Women Veterans. J Am Heart Assoc 2024; 13:e033032. [PMID: 38410963 PMCID: PMC10944021 DOI: 10.1161/jaha.123.033032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) has been associated with ischemic heart disease in women veterans, but evidence for associations with other cardiovascular disorders remains limited in this population. This retrospective longitudinal cohort study evaluated the association of PTSD with incident stroke/transient ischemic attack (TIA) in women veterans. METHODS AND RESULTS Veterans Health Administration electronic health records were used to identify women veterans aged ≥18 years engaged with Veterans Health Administration health care from January 1, 2000 to December 31, 2019. We identified women veterans with and without PTSD without a history of stroke or TIA at start of follow-up. Propensity score matching was used to match groups on age, race or ethnicity, traditional cardiovascular risk factors, female-specific risk factors, a range of mental and physical health conditions, and number of prior health care visits. PTSD, stroke, TIA, and risk factors used in propensity score matching were based on diagnostic codes. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for associations of PTSD with an incident stroke/TIA composite. Subanalyses considered stroke and TIA separately, plus age- and race- or ethnicity-stratified analyses were carried out. The analytic sample included 208 092 women veterans (104 046 with and 104 046 without PTSD). PTSD was associated with a greater rate of developing stroke/TIA (HR, 1.33 [95% CI, 1.25-1.42], P<0.001). This elevated risk was especially pronounced in women <50 years old and in Hispanic/Latina women. CONCLUSIONS Findings indicate a strong association of PTSD with incident stroke/TIA in women veterans. Research is needed to determine whether addressing PTSD and its downstream consequences can offset this risk.
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Affiliation(s)
- Ramin Ebrahimi
- Department of MedicineUniversity of CaliforniaLos AngelesCAUSA
- Department of MedicineVeterans Affairs (VA) Greater Los Angeles Healthcare SystemLos AngelesCAUSA
| | - Paul A. Dennis
- Department of Population Health SciencesDuke University School of MedicineDurhamNCUSA
- Durham VA Medical CenterDurhamNCUSA
| | - Carlos A. Alvarez
- Department of Pharmacy PracticeTexas Tech University Health Science CenterLubbockTXUSA
- Department of ResearchVA North Texas Health Care SystemDallasTXUSA
| | - A. Laurie Shroyer
- Department of Surgery, Renaissance School of MedicineStony Brook UniversityStony BrookNYUSA
- Northport VA Medical CenterNorthportNYUSA
| | - Jean C. Beckham
- Durham VA Medical CenterDurhamNCUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNCUSA
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Ebrahimi R, Dennis PA, Shroyer ALW, Tseng CH, Alvarez CA, Beckham JC, Sumner JA. Pathways Linking Post-Traumatic Stress Disorder to Incident Ischemic Heart Disease in Women: Call to Action. JACC. ADVANCES 2024; 3:100744. [PMID: 38939802 PMCID: PMC11198334 DOI: 10.1016/j.jacadv.2023.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 06/29/2024]
Abstract
Background Post-traumatic stress disorder (PTSD) is associated with increased rates of incident ischemic heart disease (IHD) in women. Objectives The purpose of this study was to determine mechanisms of the PTSD-IHD association in women. Methods In this retrospective longitudinal cohort study, data were obtained from electronic health records of all U.S. women veterans who were enrolled in Veterans Health Administration care from January 1, 2000 to December 31, 2017. Propensity score matching was used to match women with PTSD to women without PTSD on age, number of prior Veterans Health Administration visits, and presence of various traditional and nontraditional cardiovascular risk factors at index visit. Cox regression was used to model time until incident IHD diagnosis (ie, coronary artery disease, angina, or myocardial infarction) as a function of PTSD and potential mediating risk factors. Diagnoses of IHD, PTSD, and risk factors were defined by International Classification of Diseases-9th or -10th Revision, and/or Current Procedural Terminology codes. Results PTSD was associated with elevated rates of developing each risk factor. Traditional risk factors (hypertension, hyperlipidemia, smoking, diabetes) accounted for 24.2% of the PTSD-IHD association, psychiatric risk factors (eg, depression, anxiety, substance use disorders) accounted for 33.8% of the association, and all 13 risk factors accounted for 48.5% of the association. Conclusions Traditional IHD risk factors explained a quarter of the PTSD-IHD association in women veterans, and over half of the risk of IHD associated with PTSD remained unexplained even when adjusting for a wide range of risk factors. To be actionable, factors underlying the remaining PTSD-IHD association warrant timely investigation.
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Affiliation(s)
- Ramin Ebrahimi
- Department of Medicine, University of California, Los Angeles, California, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Paul A. Dennis
- Veterans Affairs Durham Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Annie Laurie W. Shroyer
- Department of Surgery, Northport Veterans Affairs Medical Center, New York, USA
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Chi-Hong Tseng
- Department of Medicine, University of California, Los Angeles, California, USA
| | - Carlos A. Alvarez
- Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, Texas, USA
- Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
| | - Jean C. Beckham
- Veterans Affairs Durham Health Care System, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer A. Sumner
- Department of Psychology, University of California, Los Angeles, California, USA
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Orshak J, Ondoma C, Johnson HM, Lauver D. Women Veterans' Barriers to Care-Seeking for Cardiovascular Disease Prevention. Nurs Res 2024; 73:26-36. [PMID: 38064302 DOI: 10.1097/nnr.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Women veterans have a high prevalence of traditional and nontraditional risks for cardiovascular disease (CVD) including obesity and posttraumatic stress disorder. Experts from the U.S. Department of Veterans Affairs have called for actions to improve the cardiovascular health of this population. One approach is to assess women veterans' barriers to care-seeking for CVD prevention, to inform future intervention research. OBJECTIVE The objective of this study was to describe women veterans' barriers to care-seeking for CVD prevention, guided by the theory of care-seeking behavior and concept awareness. METHODS Using a cross-sectional, descriptive design, a national sample of 245 women veterans participated in an online survey about barriers to care-seeking. Participants provided narrative responses to open-ended items, endorsements to closed-ended items, and rankings of their top five barriers. Researchers conducted poststratification weighting of numerical data to reflect the women veteran population. RESULTS Narrative responses described unaffordable and inaccessible services, feeling harassed or not respected in healthcare settings, and lack of awareness of risks for CVD. Frequently endorsed barriers were unaffordable and inaccessible services. Frequently ranked barriers were feeling not respected in healthcare settings and clinicians not recommending CVD prevention. DISCUSSION Findings support concepts in theory of care-seeking behavior and concept awareness. Understanding women veterans' barriers to care-seeking for CVD prevention can inform clinicians and researchers as they address these barriers.
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Ebrahimi R, Yano EM, Alvarez CA, Dennis PA, Shroyer AL, Beckham JC, Sumner JA. Trends in Cardiovascular Disease Mortality in US Women Veterans vs Civilians. JAMA Netw Open 2023; 6:e2340242. [PMID: 37902755 PMCID: PMC10616720 DOI: 10.1001/jamanetworkopen.2023.40242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/17/2023] [Indexed: 10/31/2023] Open
Abstract
Importance Cardiovascular disease (CVD) remains the leading cause of death in the US. Women veterans have higher rates of CVD compared with civilian US women; however, analyses of recent trends in mortality from cardiac disease for women veterans are lacking. Objective To investigate trends in cardiac disease mortality among women veterans over approximately the past 2 decades and compare rates with those for civilian women. Design, Setting, and Participants In this retrospective longitudinal cohort study, US Veterans Health Administration (VHA) electronic health record data, linked with the National Death Index, were analyzed for CVD trends and rates of cardiac disease mortality among women veterans (aged 18 years or older) with VHA health care encounters from January 1, 2000, to December 31, 2017. These data were compared with a national cohort of civilian women (aged 15 years or older) in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database, which provides cause-of-death data using death certificates for all US residents. The data analysis was performed between March 10, 2021, and November 28, 2022. Exposure Cardiac disease mortality among women veterans and civilian women. Main Outcomes and Measures Cardiac disease mortality was based on International Classification of Diseases, Tenth Revision diagnostic codes (I00-I09, I11, I13, and I20-I51 as defined by CDC WONDER). For women veterans and civilian women, crude and age-adjusted cardiac disease mortality rates (per 100 000 life-years) and 95% CIs were calculated, with the 2000 US general population as the reference for age-adjusted rates. Results From 2000 to 2017, 817 912 women veterans engaged with VHA health care (mean [SD] age, 45.7 [17.1] years), and 19 022 cardiac disease deaths were identified (22.4% of total deaths). The crude and age-adjusted cardiac disease mortality rates, respectively, per 100 000 life-years were 200.2 (95% CI, 181.0-221.0) and 197.6 (95% CI, 175.2-222.0) in 2000 and 196.0 (95% CI, 186.1-206.4) and 208.1 (95% CI, 196.4-220.4) in 2017, reflecting stable crude rates and a 5.3% increase in age-adjusted rates. For civilian women, the crude and age-adjusted rates decreased over time from 320.7 (95% CI, 319.7-321.8) and 268.1 (95% CI, 267.3-269.0) in 2000 to 220.9 (95% CI, 220.1-221.7) and 164.7 (95% CI, 164.1-165.3) in 2017. Conclusions and Relevance In this cohort study comparing women veterans and civilian women, cardiac disease mortality rates for women veterans did not exhibit the improvements seen for civilian women during the nearly 2-decade study period. Further research and actionable clinical interventions are warranted to improve cardiovascular care for women veterans, who represent the fastest growing group of patients within the VHA health care system.
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Affiliation(s)
- Ramin Ebrahimi
- Department of Medicine, University of California, Los Angeles
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M. Yano
- Veterans Affairs Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, University of California Los Angeles
| | - Carlos A. Alvarez
- Department of Pharmacy Practice, Texas Tech University Health Science Center, Dallas
- Department of Research, Veterans Affairs North Texas Health Care System, Dallas
| | - Paul A. Dennis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - A. Laurie Shroyer
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
- Northport Veterans Affairs Medical Center, Northport, New York
| | - Jean C. Beckham
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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Van Arsdale S, Cooper V, Bernhardt JS, Barrientos S, Messina LA, Gandhi S, Ferry LH, Shell D, Deuster PA. Bridging Total Force Fitness and Whole Health in Cardiovascular Disease Prevention. Mil Med 2023; 188:38-42. [PMID: 37665591 DOI: 10.1093/milmed/usad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/14/2023] [Accepted: 07/19/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION The Cardiovascular Disease (CVD) Prevention project is a VA-DoD initiative, supported by the Joint Incentive Fund. The goal of the project is to create an innovative, 3D virtual space within the VA-Virtual Medical Center (VA-VMC) platform that provides Veterans and Active Duty Service Members with educational resources on the prevention of CVD. MATERIALS AND METHODS The Performance Health and Wellness Center is a new center within the VA-VMC. The space enables users to explore information and actionable resources on various risk factors related to CVD through independent and provider-led instruction, using a personalized 3D avatar. RESULTS Partners of DoD and VA envision users engaging with the learning resources securely and with a sense of anonymity, which can foster self-directed learning and healthy behavior change. The DoD is particularly invested in promoting CVD prevention through the early adoption of positive health behaviors and the Total Force Fitness framework. The VA team is also committed to supporting users by providing professionally led classes and support groups on various CVD risk factors like tobacco, diabetes, nutrition, and exercise. CONCLUSIONS This project is a unique and important collaboration during a time when telehealth and telemedicine services are in greater demand. The VA-VMC advances accessible, relevant, and evidence-based educational services for DoD and VA populations, and the Performance Health and Wellness Center, itself, presents Total Force Fitness concepts and a whole-person care approach while encouraging users to be actively involved in shared decision-making with their health care providers.
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Affiliation(s)
- Stephanie Van Arsdale
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Vaughn Cooper
- Production & Delivery, Institute for Learning, Education and Development (ILEAD), Washington, DC 20420, USA
| | - Jaime S Bernhardt
- Client Relations, Institute for Learning, Education and Development (ILEAD), Washington, DC 20420, USA
| | - Stephanie Barrientos
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Lauren A Messina
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
| | - Sabina Gandhi
- Preventive Medicine Section, VA Loma Linda Healthcare System (605-111PM), Loma Linda, CA 92357, USA
| | - Linda Hyder Ferry
- Preventive Medicine Section, VA Loma Linda Healthcare System (605-111PM), Loma Linda, CA 92357, USA
- Preventive Medicine and Family Medicine Department, Loma Linda University School of Medicine, Loma Linda, CA 92350, USA
| | - Donald Shell
- Health Services Policy and Oversight OASD(HA), Disease Prevention, Disease Management and Population Health Policy & Oversight, Defense Health Headquarters, Falls Church, VA 22042, USA
| | - Patricia A Deuster
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
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Hamilton AB, Finley EP, Bean-Mayberry B, Lang A, Haskell SG, Moin T, Farmer MM. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 QUERI: study protocol for a cluster-randomized hybrid type 3 effectiveness-implementation trial. Implement Sci Commun 2023; 4:23. [PMID: 36890587 PMCID: PMC9994412 DOI: 10.1186/s43058-022-00389-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/22/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Women Veterans are the fastest-growing segment of Veterans Health Administration (VA) users. The VA has invested heavily in delivering care for women Veterans that is effective, comprehensive, and gender-tailored. However, gender disparities persist in cardiovascular (CV) and diabetes risk factor control, and the rate of perinatal depression among women Veterans is higher than that among civilian women. Challenges such as distance, rurality, negative perception of VA, discrimination (e.g., toward sexual and/or gender minority individuals), and harassment on VA grounds can further impede women's regular use of VA care. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 builds on work to date by expanding access to evidence-based, telehealth preventive and mental health services for women Veterans with high-priority health conditions in rural and urban-isolation areas. METHODS EMPOWER 2.0 will evaluate two implementation strategies, Replicating Effective Practices (REP) and Evidence-Based Quality Improvement (EBQI), in supporting the implementation and sustainment of three evidence-based interventions (Virtual Diabetes Prevention Program; Telephone Lifestyle Coaching Program; and Reach Out, Stay Strong Essentials) focused on preventive and mental health care for women Veterans. We will conduct a mixed-methods implementation evaluation using a cluster-randomized hybrid type 3 effectiveness-implementation trial design to compare the effectiveness of REP and EBQI on improved access to and rates of engagement in telehealth preventive lifestyle and mental health services. Other outcomes of interest include (a) VA performance metrics for telehealth care delivery and related clinical outcomes; (b) progression along the Stages of Implementation Completion; (c) adaptation, sensemaking, and experiences of implementation among multilevel stakeholders; and (d) cost and return on investment. We will also generate implementation playbooks for program partners to support scale-up and spread of these and future evidence-based women's health programs and policies. DISCUSSION EMPOWER 2.0 provides a model for mixed-methods hybrid type 3 effectiveness-implementation trial design incorporating evaluation of performance metrics, implementation progress, stakeholder experience, and cost and return on investment, with the ultimate goal of improving access to evidence-based preventive and mental telehealth services for women Veterans with high-priority health conditions. TRIAL REGISTRATION ClinicalTrials.gov, NCT05050266 . Registered on 20 September 2021.
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Affiliation(s)
- Alison B Hamilton
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Erin P Finley
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Departments of Medicine and Psychiatry and Behavioral Sciences, University of Texas Health Science Center, San Antonio, TX, USA
| | - Bevanne Bean-Mayberry
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ariel Lang
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Sally G Haskell
- VA HSR&D Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Tannaz Moin
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of Endocrinology, Diabetes & Metabolism, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Melissa M Farmer
- Veterans Affairs Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Gaffey AE, Rosman L, Sico JJ, Haskell SG, Brandt CA, Bathulapalli H, Han L, Dziura J, Skanderson M, Burg MM. Military sexual trauma and incident hypertension: a 16-year cohort study of young and middle-aged men and women. J Hypertens 2022; 40:2307-2315. [PMID: 35983872 DOI: 10.1097/hjh.0000000000003267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Veterans, especially women, are three times more to experience sexual harassment and assault [military sexual trauma (MST)] than civilians. As trauma is associated with elevated cardiovascular risk, we investigated whether MST independently contributes to risk for incident hypertension and whether the effects are distinct among women. METHODS We assessed 788 161 post-9/11 Veterans ( Mage = 32.14 years, 13% women) who were free of hypertension at baseline, using nationwide Veterans Health Administration data collected 2001-2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of MST to new cases of hypertension while sequentially adjusting for demographics, lifestyle and cardiovascular risk factors, including baseline blood pressure, and psychiatric disorders including posttraumatic stress disorder. We then tested for effect modification by sex. RESULTS Over 16 years [mean = 10.23 (SD: 3.69)], 35 284 Veterans screened positive for MST (67% were women). In the fully adjusted model, MST was associated with a 15% greater risk of hypertension [95% confidence interval (95% CI) 1.11-1.19]. In sex-specific analyses, men and women with a history of MST showed a 6% (95% CI, 1.00-1.12, P = 0.042) and 20% greater risk of hypertension (95% CI, 1.15-1.26, P < 0.001), respectively. CONCLUSION In this large prospective cohort of young and middle-aged Veterans, MST was associated with incident hypertension after controlling for established risk factors, including trauma-related psychiatric disorders. Although MST is disproportionately experienced by women, and the negative cardiovascular impact of MST is demonstrated for both sexes, the association with hypertension may be greater for women. Subsequent research should determine if early MST assessment and treatment attenuates this risk.
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Affiliation(s)
- Allison E Gaffey
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Jason J Sico
- VA Connecticut Healthcare System, West Haven
- Department of Neurology and Center for NeuroEpidemiological and Clinical Neurological Research
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine (General Medicine)
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven
- Department of Emergency Medicine
- Yale Center for Medical Informatics
| | - Harini Bathulapalli
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine (General Medicine)
| | - Ling Han
- Department of Internal Medicine, Program on Aging
| | - James Dziura
- VA Connecticut Healthcare System, West Haven
- Department of Emergency Medicine
| | | | - Matthew M Burg
- VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
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Allagbé I, Zeller M, Thomas D, Airagnes G, Limosin F, Boussadi A, Chagué F, Le Faou AL. Cardiovascular Risk Among Patients Who Smoke: Risk Profiles and Differences by Sex. Am J Prev Med 2022; 63:800-808. [PMID: 35773102 DOI: 10.1016/j.amepre.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Smoking is particularly harmful to the cardiovascular system, and smoking-cessation is a key target for cardiovascular prevention. From a large nationwide database on subjects who visited smoking-cessation services, this study assessed the profile and abstinence rate comparing female with male smokers at high cardiovascular risk. METHODS This was an observational study from the French smoking-cessation services cohort (French national cohort Consultations de Dépendance Tabagique) between 2001 and 2018. Inclusion criteria were being aged ≥18 years and having ≥1 cardiovascular risk factor. Abstinence was self-reported (stopping cigarettes or other tobacco products use ≥28 consecutive days) and confirmed by exhaled carbon monoxide <10 parts per million. Analysis was conducted in 2021. RESULTS Among 36,864 people who smoke, 15,407 (42%) were women. Women were 3 years younger (48 vs 51 years, p<0.001) and more educated (≥high school diploma: 54% vs 45%, p<0.001) than men. The burden of cardiovascular risk factors was slightly lower in women than in men and, for hypercholesterolemia, hypertension, diabetes, and cardiovascular diseases, were half as frequent in women as they were in men (16% vs 32%, p<0.001). However, women suffered more often from obesity, respiratory diseases, and anxiety‒depression symptoms (53% vs 39%, p<0.001). Finally, although women were less nicotine dependent, their abstinence rate was slightly lower (52.6% vs 55.2%, p<0.001). CONCLUSIONS Women who smoked had a high burden of risk factors, especially obesity and elevated rates of lung diseases, and a lower abstinence rate, with more common anxiety‒depression symptoms. Men who smoked had a higher prevalence of cardiovascular disease, higher nicotine dependence, and coaddictions. These findings highlight the need to strengthen cardiovascular prevention strategies through comprehensive sex-tailored smoking-cessation interventions.
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Affiliation(s)
- Ingrid Allagbé
- Physiopathology and Epidemiology Cerebro-cardiovascular (PEC2, EA 7460), Faculty of Health Science (UFR des Sciences de Santé), University Burgundy and Franche-Comté, Dijon, France; Outpatient Addictology Center, AP-HP Center, University of Paris, Paris, France; Groupement d'intérêt Scientifique du Réseau français d'excellence de Recherche sur Tabac, nicotine et produit connexes (GIS REfer Tab), Paris, France.
| | - Marianne Zeller
- Physiopathology and Epidemiology Cerebro-cardiovascular (PEC2, EA 7460), Faculty of Health Science (UFR des Sciences de Santé), University Burgundy and Franche-Comté, Dijon, France; Groupement d'intérêt Scientifique du Réseau français d'excellence de Recherche sur Tabac, nicotine et produit connexes (GIS REfer Tab), Paris, France
| | - Daniel Thomas
- Groupement d'intérêt Scientifique du Réseau français d'excellence de Recherche sur Tabac, nicotine et produit connexes (GIS REfer Tab), Paris, France; Institut de Cardiologie, Hôpital Pitié Salpêtrière, AP-HP, Université Paris-Sorbonne, Paris, France
| | - Guillaume Airagnes
- Outpatient Addictology Center, AP-HP Center, University of Paris, Paris, France
| | - Frédéric Limosin
- DMU Psychiatry and Addictology, AP-HP Centre-University of Paris, Paris, France
| | - Abdelali Boussadi
- Medical Informatics, Biostatistics and Public Health Department, Georges Pompidou University Hospital, Paris, France
| | - Frédéric Chagué
- Groupement d'intérêt Scientifique du Réseau français d'excellence de Recherche sur Tabac, nicotine et produit connexes (GIS REfer Tab), Paris, France; Cardiology Department, Dijon University Hospital, Dijon, France
| | - Anne-Laurence Le Faou
- Outpatient Addictology Center, AP-HP Center, University of Paris, Paris, France; Groupement d'intérêt Scientifique du Réseau français d'excellence de Recherche sur Tabac, nicotine et produit connexes (GIS REfer Tab), Paris, France; DMU Psychiatry and Addictology, AP-HP Centre-University of Paris, Paris, France; University Hospital Federation - Network of Research in Substance Use Disorder, Paris, France
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Habbal AB, White CT, Shamim H, Al Shouli R, Mohammed L. Posttraumatic Stress Disorder (PTSD) and Instigation of Cardiovascular Events: Ischemic Heart Disease (IHD) and Atrial Fibrillation (AF). Cureus 2022; 14:e30583. [PMID: 36420248 PMCID: PMC9678112 DOI: 10.7759/cureus.30583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 10/22/2022] [Indexed: 06/16/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) is a disorder with chronic deterioration that arises after exposure to traumatic events. In these events, a persistent maladaptive reaction was found as a result of severe psychological stress and trauma. It is usually accompanied by mood alteration, disturbing memories, evading behavior, and hyperarousal. Many studies found a connection between PTSD and both ischemic heart disease (IHD) and atrial fibrillation (AF). Impairment of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system can contribute to hypercoagulability, elevated cardiac reactivity, hypertension, dyslipidemia, and chronic inflammation, as all of these processes are implicated in IHD and AF risk. PTSD tends to have a more long-term course and is associated with more autonomic reactivity rather than a direct negative impact. More research is needed to understand the mechanisms underlying the increased AF risk in patients with PTSD and to identify supposed objectives for screening, intervention, and treatment. Highlighting the connection between PTSD and cardiovascular events would lead clinicians to develop screening tests that might help with the prevention and treatment of cardiovascular events for these patients.
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Affiliation(s)
- Ahmad B Habbal
- Cardiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Chantelle T White
- Psychology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Humaira Shamim
- Dermatology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Roba Al Shouli
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Galovski TE, Street AE, Creech S, Lehavot K, Kelly UA, Yano EM. State of the Knowledge of VA Military Sexual Trauma Research. J Gen Intern Med 2022; 37:825-832. [PMID: 36042078 PMCID: PMC9481813 DOI: 10.1007/s11606-022-07580-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.
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Affiliation(s)
- Tara E Galovski
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA, 02130, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
| | - Amy E Street
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Street, Boston, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Suzannah Creech
- VA VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas VA, Waco, TX, USA
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Keren Lehavot
- VA HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Ursula A Kelly
- Atlanta VA Health Care System, Atlanta, GA, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA, USA
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Saban KL, Collins EG, Mathews HL, Bryant FB, Tell D, Gonzalez B, Bhoopalam S, Chroniak CP, Janusek LW. Impact of a Mindfulness-Based Stress Reduction Program on Psychological Well-Being, Cortisol, and Inflammation in Women Veterans. J Gen Intern Med 2022; 37:751-761. [PMID: 36042095 PMCID: PMC9481828 DOI: 10.1007/s11606-022-07584-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 04/01/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Women veterans experience higher levels of stress-related symptoms than their civilian counterparts. Psychological stress is associated with greater inflammation and may increase risk for cardiovascular disease (CVD). Mindfulness-based stress reduction (MBSR) has been found to improve psychological well-being in other populations but no randomized controlled trials (RCT) have been conducted examining the impact of MBSR on well-being and inflammation in women veterans at risk for CVD. OBJECTIVE Determine the effectiveness of MBSR in improving psychological well-being, cortisol, and inflammation associated with CVD in women veterans. DESIGN The design is a RCT comparing MBSR to an active control condition (ACC) consisting of a health education program. PARTICIPANTS Women veterans (N=164) with risk factors for CVD from the Chicagoland area participated in the study. INTERVENTION An 8-week MBSR program with weekly 2.5-h classes was compared to an ACC consisting of an 8-week health promotion education program with weekly 2.5-h classes. MAIN MEASURES The outcomes were psychological well-being [perceived stress, depressive symptoms, loneliness, and post-traumatic stress disorder (PTSD)] symptoms and stress-related markers, including diurnal salivary cortisol and cytokines interleukin-6 (IL-6) and interferon gamma (IFN-γ). Data were collected at baseline, 4 weeks (mid-point of intervention), 8 weeks (completion of intervention), and 6 months after completion of MBSR or ACC. KEY RESULTS Compared to the ACC, women who participated in MBSR reported less perceived stress, loneliness, and symptoms of PTSD. Although there were no significant differences between groups or changes over time in IL-6 or IFN-γ, participants in the MBSR program demonstrated a more rapid decline in diurnal salivary cortisol as compared to those in the ACC. CONCLUSIONS MBSR was found to improve psychological well-being and decrease diurnal salivary cortisol in women veterans at risk for CVD. Health care providers may consider MBSR for women veterans as a means by which to improve their psychological well-being.
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Affiliation(s)
- Karen L Saban
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA, 5000 S. 5th Ave., Hines, IL, 60141, USA. .,Marcella Niehoff School of Nursing, Loyola University Chicago, 2160 S. First Ave, Center for Translational Research and Education, Maywood, IL, 60153, USA.
| | - Eileen G Collins
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA, 5000 S. 5th Ave., Hines, IL, 60141, USA.,Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, 845 S. Damen Ave. MC 902, Chicago, IL, 60612, USA
| | - Herbert L Mathews
- Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Center for Translational Research and Education, Maywood, IL, 60153, USA
| | - Fred B Bryant
- Department of Psychology, Loyola University Chicago, 1032 W. Sheridan Road, Coffey Hall Rm. 242, Chicago, IL, 60660, USA
| | - Dina Tell
- Marcella Niehoff School of Nursing, Loyola University Chicago, 2160 S. First Ave, Center for Translational Research and Education, Maywood, IL, 60153, USA
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA, 5000 S. 5th Ave., Hines, IL, 60141, USA
| | - Sudha Bhoopalam
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA, 5000 S. 5th Ave., Hines, IL, 60141, USA
| | | | - Linda Witek Janusek
- Marcella Niehoff School of Nursing, Loyola University Chicago, 2160 S. First Ave, Center for Translational Research and Education, Maywood, IL, 60153, USA
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Lumsden RH, Goldstein KM, Shephard-Banigan M, Kroll-Desrosiers A, Bean-Mayberry B, Farmer MM, Mattocks KM. Racial Differences in Nontraditional Risk Factors Associated with Cardiovascular Conditions in Pregnancy Among U.S. Women Veterans. J Womens Health (Larchmt) 2022; 31:706-714. [PMID: 35072546 DOI: 10.1089/jwh.2021.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Pregnancy-related cardiovascular (CV) conditions are important predictors of future cardiovascular disease (CVD). Nontraditional factors, such as depression and chronic stress, have been associated with CVD, but their role in pregnancy-related CVD conditions (pCVD) remains unknown. To determine the association between nontraditional factors and CV conditions in pregnancy, and to explore if this risk varies by race. Methods: Using data from a prospective study of pregnant women within the veterans affairs health system (COMFORT study), we described the prevalence of nontraditional factors (e.g., depression, post-traumatic stress disorder [PTSD], chronic stress) and used logistic regression to determine the association between nontraditional factors and pregnancy-related CV conditions (pre-eclampsia/eclampsia, gestational hypertension, gestation diabetes, or preterm delivery). Analyses were then stratified by race. Results: Among 706 enrollees, 26% had pregnancy-related CV conditions. These women had significantly higher rates of depression (62% vs. 45%, p < 0.01), anxiety (50% vs. 37%, p = 0.01), PTSD (44% vs. 29%, p < 0.01), and high stress levels before pregnancy (22% vs. 16%, p = 0.05) compared with women with normal pregnancies. Overall, these factors were not associated with increased adjusted odds of pCVD. Overall, Black women had disproportionately higher rates of prepregnancy hypertension compared with White women (22% vs. 6%, p < 0.01). Conclusions: Women Veterans with pCVD are a high-risk group for future CVD, with disproportionately high rates of depression, anxiety, PTSD, and chronic stress. Racial disparities exist in pregnancy-related CV risk factors, which may further compound existing racial disparities in CVD among women Veterans.
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Affiliation(s)
- Rebecca H Lumsden
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen M Goldstein
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham VA Health Care System, Durham, North Carolina, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA healthcare system, Durham, North Carolina, USA
| | - Megan Shephard-Banigan
- Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke-Margolis Center for Health Policy, Duke University Durham, North Carolina, USA
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Bevanne Bean-Mayberry
- VA Greater Los Angeles Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California, USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Melissa M Farmer
- VA Greater Los Angeles Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit. Womens Health Issues 2022; 32:284-292. [PMID: 35115227 DOI: 10.1016/j.whi.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes. METHODS We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings. RESULTS Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers. CONCLUSIONS Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.
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Rippetoe M, Mangi AA. The Impact of Sex on Strength Training in Adults With Cardiovascular Disease. Clin Ther 2022; 44:442-449. [DOI: 10.1016/j.clinthera.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/07/2022] [Accepted: 01/09/2022] [Indexed: 02/03/2023]
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Upchurch DM, Wong MS, Yuan AH, Haderlein TP, McClendon J, Christy A, Washington DL. COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences. Womens Health Issues 2022; 32:41-50. [PMID: 34702652 PMCID: PMC8486675 DOI: 10.1016/j.whi.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the COVID-19 pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration. Little is known about gender-specific factors associated with infection among veterans. This study seeks to fill this gap. METHODS The sample was veterans with results from a COVID-19 test (polymerase chain reaction) conducted at Veterans Health Administration facilities between March 1, 2020, and August 5, 2020, and linked to the Centers for Disease Control and Prevention Social Vulnerability Index data (39,223 women and 316,380 men). Bivariate, multivariate logistic, and predicted probability analyses were conducted. All analyses were stratified by gender. RESULTS Similar percentages of women and men tested positive for COVID-19 (9.6% vs. 10.0%). In multivariate analysis, compared with non-Hispanic White women, American Indian/Alaska Native, Black, and Hispanic women all had significantly higher odds of infection. Similar racial/ethnic differences were found for men. Both older men and women (>40 years) had lower odds of infection, but the age cut points differed (40 for women, 55 for men). Men 80 years and older had a higher odds than those aged less than 40 years of age. For men, but not for women, being employed (vs. unemployed) was associated with an increased odds of infection, and having comorbidities was associated with decreased odds. There were significant differences within and across gender-by-race/ethnicity in infection, after adjusting for covariates. CONCLUSIONS American Indian/Alaska Native, Hispanic, and Black women and men veterans are disproportionately impacted by COVID-19 infection. Widespread testing and tracking, education, and outreach regarding COVID-19 mitigation and vaccination efforts are recommended.
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Affiliation(s)
- Dawn M Upchurch
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Anita H Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Taona P Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Juliette McClendon
- National Center for PTSD, Women's Health Science Division, VA Boston Health Care System, Boston, Massachusetts; Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Alicia Christy
- Women's Health Services, Veterans Health Administration, Washington, District of Columbia
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
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20
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The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study. Womens Health Issues 2021; 32:274-283. [PMID: 34949527 DOI: 10.1016/j.whi.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes. METHODS The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use. RESULTS The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31). CONCLUSIONS Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.
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21
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Gaffey AE, Burg MM, Rosman L, Portnoy GA, Brandt CA, Cavanagh CE, Skanderson M, Dziura J, Mattocks KM, Bastian LA, Haskell SG. Baseline Characteristics from the Women Veterans Cohort Study: Gender Differences and Similarities in Health and Healthcare Utilization. J Womens Health (Larchmt) 2021; 30:944-955. [PMID: 33439756 PMCID: PMC8290312 DOI: 10.1089/jwh.2020.8732] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lindsey Rosman
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Galina A. Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Casey E. Cavanagh
- Department of Psychiatry and Neurobehavioral Sciences, Charlottesville, Virginia, USA
| | | | - James Dziura
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristin M. Mattocks
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Research and Development, VA Central Western Massachusetts and Department of Quantitative Health Science, University of Massachusetts Medical School, Leeds, Massachusetts, USA
| | - Lori A. Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine (General), Yale School of Medicine, New Haven, Connecticut, USA
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine (General), Yale School of Medicine, New Haven, Connecticut, USA
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22
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Ebrahimi R, Lynch KE, Beckham JC, Dennis PA, Viernes B, Tseng CH, Shroyer ALW, Sumner JA. Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans. JAMA Cardiol 2021; 6:642-651. [PMID: 33729463 DOI: 10.1001/jamacardio.2021.0227] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking. Objective To determine whether PTSD is associated with incident IHD in women veterans. Design, Setting, and Participants In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020. Exposures PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters. Main Outcomes and Measures Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes. Results A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38). Conclusions and Relevance This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.
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Affiliation(s)
- Ramin Ebrahimi
- Department of Medicine, Cardiology Section, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California.,Department of Medicine, UCLA (University of California, Los Angeles)
| | - Kristine E Lynch
- Department of Medicine, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, University of Utah, Salt Lake City
| | - Jean C Beckham
- Department of Psychiatry, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Department of Psychology, Duke School of Medicine, Durham, North Carolina
| | - Paul A Dennis
- Department of Psychiatry, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Department of Psychology, Duke School of Medicine, Durham, North Carolina
| | - Benjamin Viernes
- Department of Medicine, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah.,Department of Internal Medicine, University of Utah, Salt Lake City
| | - Chi-Hong Tseng
- Department of Medicine, UCLA (University of California, Los Angeles)
| | - A Laurie W Shroyer
- Department of Surgery, Northport Veterans Affairs Medical Center, Northport, New York.,Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
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23
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Tsai S, Nguyen H, Ebrahimi R, Barbosa MR, Ramanan B, Heitjan DF, Hastings JL, Modrall JG, Jeon-Slaughter H. COVID-19 associated mortality and cardiovascular disease outcomes among US women veterans. Sci Rep 2021; 11:8497. [PMID: 33875764 PMCID: PMC8055870 DOI: 10.1038/s41598-021-88111-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/01/2021] [Indexed: 12/13/2022] Open
Abstract
The burden of COVID-19 has been noted to be disproportionately greater in minority women, a population that is nevertheless still understudied in COVID-19 research. We conducted an observational study to examine COVID-19-associated mortality and cardiovascular disease outcomes after testing (henceforth index) among a racially diverse adult women veteran population. We assembled a retrospective cohort from a Veterans Affairs (VA) national COVID-19 shared data repository, collected between February and August 2020. A case was defined as a woman veteran who tested positive for SARS-COV-2, and a control as a woman veteran who tested negative. We used Kaplan-Meier curves and the Cox proportional hazards model to examine the distribution of time to death and the effects of baseline predictors on mortality risk. We used generalized linear models to examine 60-day cardiovascular disease outcomes. Covariates studied included age, body mass index (BMI), and active smoking status at index, and pre-existing conditions of diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and a history of treatment with antiplatelet or anti-thrombotic drug at any time in the 2 years prior to the index date. Women veterans who tested positive for SARS-CoV-2 had 4 times higher mortality risk than women veterans who tested negative (Hazard Ratio 3.8, 95% Confidence Interval CI 2.92 to 4.89) but had lower risk of cardiovascular events (Odds Ratio OR 0.78, 95% CI 0.66 to 0.92) and developing new heart disease conditions within 60 days (OR 0.67, 95% CI 0.58 to 0.77). Older age, obesity (BMI > 30), and prior CVD and COPD conditions were positively associated with increased mortality in 60 days. Despite a higher infection rate among minority women veterans, there was no significant race difference in mortality, cardiovascular events, or onset of heart disease. SARS-CoV-2 infection increased short-term mortality risk among women veterans similarly across race groups. However, there was no evidence of increased cardiovascular disease incidence in 60 days. A longer follow-up of women veterans who tested positive is warranted.
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Affiliation(s)
- Shirling Tsai
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hang Nguyen
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Southern Methodist University, Dallas, TX, USA
| | - Ramin Ebrahimi
- Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, CA, USA
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Monica R Barbosa
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bala Ramanan
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Daniel F Heitjan
- Southern Methodist University, Dallas, TX, USA
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeffrey L Hastings
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Gregory Modrall
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Haekyung Jeon-Slaughter
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA.
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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24
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Jeon-Slaughter H, Chen X, Tsai S, Ramanan B, Ebrahimi R. Developing an Internally Validated Veterans Affairs Women Cardiovascular Disease Risk Score Using Veterans Affairs National Electronic Health Records. J Am Heart Assoc 2021; 10:e019217. [PMID: 33619994 PMCID: PMC8174271 DOI: 10.1161/jaha.120.019217] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The current American College of Cardiology/American Heart Association women cardiovascular disease (CVD) risk score suboptimally estimates CVD risk for young and minority women in the military. The current study developed an internally validated CVD risk score for women military service members and veterans using the Veterans Affairs (VA) national electronic health records data. Methods and Results The study cohort included 69 574 White, Black, and Hispanic women service members and veterans aged 30 to 79 years in 2007 treated in the VA Health Care System between January 1, 2007 and December 31, 2017 (henceforth, VA women). Stratified by race and ethnicity, the new VA women CVD risk model estimated risk coefficients and 10‐year CVD risk using a time‐variant covariate Cox model. Harrell C‐statistics, calibration plots, and net classification index were used to assess accuracy and prognostic performance of the new VA women CVD risk model. The new internally validated VA women CVD risk score performed better in predicting VA women 10‐year atherosclerosis cardiovascular disease risk than the pooled cohort American College of Cardiology/American Heart Association risk score in both accuracy (White Harrell C‐statistics, 70% versus 61%; Black, 68% versus 63%) and prognostic performance (White net classification index, 0.31; 95% CI, 0.26–0.33; Black net classification index, 0.06; 95% CI, 0.03–0.09). Conclusions The proposed VA women CVD risk score improves accuracy of the existing American College of Cardiology/American Heart Association CVD risk assessment tool in predicting long‐term CVD risk for VA women, particularly in young and racial/ethnic minority women.
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Affiliation(s)
- Haekyung Jeon-Slaughter
- Veterans Affairs North Texas Health Care System Dallas TX.,Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Xiaofei Chen
- Veterans Affairs North Texas Health Care System Dallas TX.,Southern Methodist University Dallas TX
| | - Shirling Tsai
- Veterans Affairs North Texas Health Care System Dallas TX.,Department of Surgery University of Texas Southwestern Medical Center Dallas TX
| | - Bala Ramanan
- Veterans Affairs North Texas Health Care System Dallas TX.,Department of Surgery University of Texas Southwestern Medical Center Dallas TX
| | - Ramin Ebrahimi
- Veterans Affairs Greater Los Angeles Health Care System Los Angeles CA.,Department of Medicine University of California at Los Angeles CA
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25
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Bond RM, Gaither K, Nasser SA, Albert MA, Ferdinand KC, Njoroge JN, Parapid B, Hayes SN, Pegus C, Sogade B, Grodzinsky A, Watson KE, McCullough CA, Ofili E. Working Agenda for Black Mothers: A Position Paper From the Association of Black Cardiologists on Solutions to Improving Black Maternal Health. Circ Cardiovasc Qual Outcomes 2021; 14:e007643. [PMID: 33563007 PMCID: PMC7887097 DOI: 10.1161/circoutcomes.120.007643] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Following decades of decline, maternal mortality began to rise in the United States around 1990—a significant departure from the world’s other affluent countries. By 2018, the same could be seen with the maternal mortality rate in the United States at 17.4 maternal deaths per 100 000 live births. When factoring in race/ethnicity, this number was more than double among non-Hispanic Black women who experienced 37.1 maternal deaths per 100 000 live births. More than half of these deaths and near deaths were from preventable causes, with cardiovascular disease being the leading one. In an effort to amplify the magnitude of this epidemic in the United States that disproportionately plagues Black women, on June 13, 2020, the Association of Black Cardiologists hosted the Black Maternal Heart Health Roundtable—a collaborative task force to tackle the maternal health crisis in the Black community. The roundtable brought together diverse stakeholders and champions of maternal health equity to discuss how innovative ideas, solutions and opportunities could be implemented, while exploring additional ways attendees could address maternal health concerns within the health care system. The discussions were intended to lead the charge in reducing maternal morbidity and mortality through advocacy, education, research, and collaborative efforts. The goal of this roundtable was to identify current barriers at the community, patient, and clinician level and expand on the efforts required to coordinate an effective approach to reducing these statistics in the highest risk populations. Collectively, preventable maternal mortality can result from or reflect violations of a variety of human rights—the right to life, the right to freedom from discrimination, and the right to the highest attainable standard of health. This is the first comprehensive statement on this important topic. This position paper will generate further research in disparities of care and promote the interest of others to pursue strategies to mitigate maternal mortality.
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Affiliation(s)
- Rachel M Bond
- Women's Heart Health, Dignity Health, AZ (R.M.B.).,Internal Medicine, Creighton University School of Medicine, Chandler, AZ (R.M.B.)
| | - Kecia Gaither
- Perinatal Services and Maternal-Fetal Medicine, NYC Health + Hospitals/Lincoln, Bronx (K.G.)
| | - Samar A Nasser
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.G.)
| | - Michelle A Albert
- Medicine, UCSF School of Medicine, Center for the Study of Adversity and Cardiovascular Disease (M.A.A.)
| | | | - Joyce N Njoroge
- Department of Medicine, Division of Cardiology, University of California, San Francisco (J.N.N.)
| | | | | | - Cheryl Pegus
- Cambia Health Solution (C.P.).,Consumer Health Solutions (C.P.)
| | - Bola Sogade
- ObGyne Birth Center for Natural Deliveries (B.S.)
| | - Anna Grodzinsky
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.G.).,University of Missouri-Kansas City (A.G.)
| | - Karol E Watson
- Medicine/Cardiology, UCLA School of Medicine (K.E.W.).,UCLA Program in Preventive Cardiology (K.E.W.).,UCLA Barbra Streisand Women's Heart Health Program (K.E.W.)
| | | | - Elizabeth Ofili
- Medicine (Cardiology), Morehouse School of Medicine (E.O.).,Morehouse Choice Accountable Care Organization (E.O.)
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26
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Weeda ER, Bishu KG, Ward R, Axon RN, Taber DJ, Gebregziabher M. Joint effect of race/ethnicity or location of residence and sex on low density lipoprotein-cholesterol among veterans with type 2 diabetes: a 10-year retrospective cohort study. BMC Cardiovasc Disord 2020; 20:449. [PMID: 33059602 PMCID: PMC7558630 DOI: 10.1186/s12872-020-01730-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. Managing dyslipidemia is important in the prevention of CV mortality. However, the impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. Therefore, we sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D). METHODS Veterans Health Administration and Centers for Medicare and Medicaid Services data were used to perform a longitudinal cohort study of veterans with T2D (2007-2016). Mixed effects logistic regression with a random intercept was used to model the association between sex and low-density lipoprotein (LDL) > 100 mg/dL and its interaction with race/ethnicity and location of residence after adjusting for all measured covariates. RESULTS When female sex and rural location of residence were both present, they were associated with an antagonistic harmful effect on LDL. Similar antagonistic harmful effects on LDL were observed when the joint effect of female sex and several minority race/ethnicity groups were evaluated. After adjusting for measured covariates, the odds of LDL > 100 mg/dL were higher for urban women (OR = 2.66, 95%CI 2.48-2.85) and rural women (OR = 3.26, 95%CI 2.94-3.62), compared to urban men. The odds of LDL > 100 mg/dL was the highest among non-Hispanic Black (NHB) women (OR = 5.38, 95%CI 4.45-6.51) followed by non-Hispanic White (NHW) women (OR = 2.59, 95%CI 2.44-2.77), and Hispanic women (OR = 2.56, 95%CI 1.79-3.66). CONCLUSION Antagonistic harmful effects on LDL were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were also present when evaluating the joint effect of female sex and several minority race/ethnicity groups. Disparities were most pronounced in NHB and rural women, who had 5.4 and 3.3 times the odds of elevated LDL versus NHW and urban men after adjusting for important covariates. These striking effect sizes in a population at high cardiovascular risk (i.e., older with T2D) suggest interventions aimed at improving lipid management are needed for individuals falling into one or more groups known to face health disparities.
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Affiliation(s)
- Erin R. Weeda
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, USA
| | - Kinfe G. Bishu
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, USA
| | - Ralph Ward
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, USA
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, 135 Cannon Street, Charleston, SC 29425 USA
| | - R. Neal Axon
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, USA
- Department of Medicine, College of Medicine, Medical University of South Carolina, Charleston, USA
| | - David J. Taber
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, USA
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, USA
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, USA
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, 135 Cannon Street, Charleston, SC 29425 USA
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Chen X, Ramanan B, Tsai S, Jeon‐Slaughter H. Differential Impact of Aging on Cardiovascular Risk in Women Military Service Members. J Am Heart Assoc 2020; 9:e015087. [PMID: 32515249 PMCID: PMC7429070 DOI: 10.1161/jaha.120.015087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/30/2020] [Indexed: 01/08/2023]
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD) is the third leading cause of death in women service members and veterans. This study assessed 10-year ASCVD risk in women service members and veterans using their own electronic health record data extracted from Veterans Affairs (VA) national Corporate Data Warehouse database. Methods and Results We retrospectively followed 69 574 VA women, aged 30 to 79 years, from 2007 to 2017. Of these, 52% were whites (n=36 172), 42% were blacks (n=29 232), and 6% were Hispanics (n=4171). Risk factors and ASCVD events (nonfatal myocardial infarction, nonfatal stroke, and cardiac deaths) were identified using diagnostic and procedural codes from electronic health records. Then, within the same construct of the current American College of Cardiology/American Heart Association 10-year ASCVD risk assessment models for women, coefficients for risks factors were recalculated using the VA national electronic health record data, stratified by race (hereafter, VA women model). Our study found a curvilinear association of aging with increased risk of 10-year ASCVD event in VA women starting at ages as young as 30 years across all race groups. The VA women model performance in predicting ASCVD events at 10 years was mixed-moderate in discrimination (C statistics, 0.61-0.64) but good in accuracy, as demonstrated by calibration plots approximating a 45° line. Conclusions The study finding, a curvilinear association of aging with increased ASCVD risk in VA women across all races, demonstrates the need for cardiovascular risk screening of younger VA women, aged <45 years.
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Affiliation(s)
- Xiaofei Chen
- Veterans Affairs North Texas Health Care SystemDallasTX
- Southern Methodist UniversityDallasTX
| | - Bala Ramanan
- Veterans Affairs North Texas Health Care SystemDallasTX
- Department of SurgeryUniversity of Texas Southwestern Medical CenterDallasTX
| | - Shirling Tsai
- Veterans Affairs North Texas Health Care SystemDallasTX
- Department of SurgeryUniversity of Texas Southwestern Medical CenterDallasTX
| | - Haekyung Jeon‐Slaughter
- Veterans Affairs North Texas Health Care SystemDallasTX
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTX
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