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Gaffey AE, Chang TE, Brandt CA, Haskell SG, Dhruva SS, Bastian LA, Levine A, Melissa S, Burg MM. Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health. medRxiv 2024:2024.04.22.24306203. [PMID: 38712220 PMCID: PMC11071551 DOI: 10.1101/2024.04.22.24306203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.
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Herb Neff KM, Buta E, Fenn LM, Ramsey CN, Snow JL, Haskell SG, Masheb RM. Distinguishing probable atypical anorexia nervosa from weight loss alone in a national sample of U.S. Military Veterans: Disentangling the roles of weight suppression and cognitive concerns. Int J Eat Disord 2024; 57:827-838. [PMID: 38129986 DOI: 10.1002/eat.24116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Veterans are at high risk for eating disorders (EDs), and specifically for atypical anorexia nervosa (atypical AN). The current study aimed to better understand this under-studied disorder and how it differs from weight loss without ED cognitive features. METHOD Secondary analyses were conducted with data from a national study of Veterans (N = 882, 49.4% women). Participants were categorized into four mutually exclusive groups using the Eating Disorder Diagnostic Scale 5: probable atypical AN, a cognitive concerns group (Cog Only), a weight suppressed group (WS Only), and a no ED control group. Adjusted regression models were used to compare groups on measures of eating pathology and mental health. Three weight suppression thresholds (5%, 10%, and 15%) for probable atypical AN were also tested. RESULTS The sample was comprised of 12% probable atypical AN, 23.6% Cog Only, 16.3% WS Only, and 48.1% Control. The probable atypical AN group was most like the Cog Only group except for higher levels of dietary restraint. Atypical AN fared worse and was least like the Control group followed by the WS Only group. All weight suppression thresholds significantly predicted dietary restraint, with 5% being the best predictor. DISCUSSION Results found that probable atypical AN is a distinct clinical entity and that the exact weight suppression threshold associated with atypical AN is less important than having any weight suppression. Findings highlight the clinical significance of atypical AN and the importance of gaining a better understanding of how to address this clinical entity. PUBLIC SIGNIFICANCE Atypical anorexia nervosa is a relatively underexamined but highly prevalent eating disorder in the Veteran population. Results show that ED cognitive features are more closely linked to clinically significant eating pathology and poor mental health than weight suppression alone suggesting that negative thinking about weight gain and appearance, regardless of the presence or severity of weight loss, may signal the need for specialized intervention.
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Affiliation(s)
| | - Eugenia Buta
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Lindsay M Fenn
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Christine N Ramsey
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
- University of Texas at Austin, Austin, Texas, USA
| | - Jennifer L Snow
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Robin M Masheb
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Yale School of Medicine, New Haven, Connecticut, USA
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Chui PW, Khokhar A, Gordon KS, Dziura J, Burg MM, Brandt C, Haskell SG, Malm B, Bastian LA, Gandhi PU. Opioid prescription and risk of atrial fibrillation in younger veterans. Am Heart J 2024; 268:61-67. [PMID: 37949420 DOI: 10.1016/j.ahj.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Opioids may play a part in the development of atrial fibrillation (AF). Understanding the relationship between opioid exposure and AF can help providers better assess the risk and benefits of prescribing opioids. OBJECTIVE To assess the incidence of AF as a function of prescribed opioids and opioid type. DESIGN We performed unadjusted and adjusted time-updated Cox regressions to assess the association between opioid exposure and incident AF. PARTICIPANTS The national study sample was comprised of Veterans enrolled in the Veterans Health Administration (VHA) who served in support of post-9/11 operations. MAIN MEASURES The main predictor of interest was prescription opioid exposure, which was treated as a time-dependent variable. The first was any opioid exposure (yes/no). Secondary was opioid type. The outcome, incident AF, was identified through ICD-9-CM diagnostic codes at any primary care visit after the baseline period. KEY RESULTS A total of 609,763 veterans (mean age: 34 years and 13.24% female) were included in our study. Median follow-up time was 4.8 years. Within this cohort, 124,395 veterans (20.40%) were prescribed an opioid. A total of 1,455 Veterans (0.24%) were diagnosed with AF. In adjusted time-updated Cox regressions, the risk of incident AF was higher in the veterans prescribed opioids (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.38-1.57). In adjusted time-updated Cox regressions, both immunomodulating and nonimmunomodulating opioid type was associated with increased risk of incident AF (HR: 1.40; 95% CI: 1.25-1.57 and HR: 1.49; 95% CI: 1.39-1.60), compared to no opioid use, respectively. CONCLUSIONS Our findings suggest opioid prescription may be a modifiable risk factor for the development of AF.
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Affiliation(s)
- Philip W Chui
- Kaiser Los Angeles Medical Center, Section of Cardiology, Los Angeles, CA; Southern California Heart Center, San Gabriel, CA
| | - Arshjot Khokhar
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kirsha S Gordon
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT; Yale Center for Analytical Sciences, School of Public Health, Yale University School of Medicine, New Haven, CT
| | - James Dziura
- Yale Center for Analytical Sciences, School of Public Health, Yale University School of Medicine, New Haven, CT
| | - Matthew M Burg
- VA Connecticut Health System, West Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Cynthia Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Brian Malm
- VA Connecticut Health System, West Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.
| | - Parul U Gandhi
- VA Connecticut Health System, West Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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Combellick JL, Esmaeili A, Johnson AM, Haskell SG, Phibbs CS, Manzo L, Miller LJ. Perinatal mental health and pregnancy-associated mortality: opportunities for change. Arch Womens Ment Health 2024:10.1007/s00737-023-01404-2. [PMID: 38172275 DOI: 10.1007/s00737-023-01404-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Abstract
Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.
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Affiliation(s)
- Joan L Combellick
- Department of Veterans Affairs, Veterans Health Administration, Office of Women's Health, 810 Vermont Ave NW, Washington, DC, 20420, USA.
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA.
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, USA.
| | - Aryan Esmaeili
- Health Economics Resource Center (HERC), Palo Alto VA Medical Center, 795 Willow Road, Menlo Park, Palo Alto, CA, 94025, USA
| | - Amanda M Johnson
- Department of Veterans Affairs, Veterans Health Administration, Office of Women's Health, 810 Vermont Ave NW, Washington, DC, 20420, USA
| | - Sally G Haskell
- Department of Veterans Affairs, Veterans Health Administration, Office of Women's Health, 810 Vermont Ave NW, Washington, DC, 20420, USA
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT, 06516, USA
- School of Medicine, Yale University, 333 Cedar St, New Haven, CT, 06510, USA
| | - Ciaran S Phibbs
- Health Economics Resource Center (HERC), Palo Alto VA Medical Center, 795 Willow Road, Menlo Park, Palo Alto, CA, 94025, USA
- Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA, 94304, USA
| | - Laura Manzo
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, USA
- US Army, AMEDD Student Detachment, 187th Medical Battalion, Joint Base San Antonio, San Antonio, TX, 78234, USA
| | - Laura J Miller
- Department of Veterans Affairs, Veterans Health Administration, Women's Mental Health, Office of Mental Health and Suicide Prevention, 810 Vermont Ave NW, Washington, DC, 20420, USA
- Department of Psychiatry and Behavioral Sciences, Stritch School of Medicine, Loyola University, 2160 South First Avenue, Maywood, IL, 60153, USA
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Combellick JL, Basile Ibrahim B, Esmaeili A, Phibbs CS, Johnson AM, Patton EW, Manzo L, Haskell SG. Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions. Int J Environ Res Public Health 2023; 21:37. [PMID: 38248502 PMCID: PMC10815856 DOI: 10.3390/ijerph21010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/23/2024]
Abstract
The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.
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Affiliation(s)
- Joan L. Combellick
- Department of Veterans Affairs, Veterans Health Administration, Office of Women’s Health, 810 Vermont Ave NW, Washington, DC 20420, USA; (A.M.J.); (E.W.P.); (S.G.H.)
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT 06477, USA; (B.B.I.); (L.M.)
| | - Bridget Basile Ibrahim
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT 06477, USA; (B.B.I.); (L.M.)
| | - Aryan Esmaeili
- Health Economics Resource Center (HERC), Palo Alto VA Medical Center, Menlo Park 795 Willow Road, Palo Alto, CA 94025, USA; (A.E.); (C.S.P.)
| | - Ciaran S. Phibbs
- Health Economics Resource Center (HERC), Palo Alto VA Medical Center, Menlo Park 795 Willow Road, Palo Alto, CA 94025, USA; (A.E.); (C.S.P.)
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Amanda M. Johnson
- Department of Veterans Affairs, Veterans Health Administration, Office of Women’s Health, 810 Vermont Ave NW, Washington, DC 20420, USA; (A.M.J.); (E.W.P.); (S.G.H.)
| | - Elizabeth Winston Patton
- Department of Veterans Affairs, Veterans Health Administration, Office of Women’s Health, 810 Vermont Ave NW, Washington, DC 20420, USA; (A.M.J.); (E.W.P.); (S.G.H.)
- VA Boston Health Care System, 150 South Huntington Avenue, Boston, MA 02130, USA
- Department of Obstetrics and Gynecology, Chobanian & Avedisian School of Medicine, Boston University, 771 Albany St, Dowling 4, Boston, MA 02118, USA
| | - Laura Manzo
- School of Nursing, Yale University, 400 West Campus Drive, Orange, CT 06477, USA; (B.B.I.); (L.M.)
- US Army, AMEDD Student Detachment, 187th Medical Battalion, Joint Base San Antonio, San Antonio, TX 78234, USA
| | - Sally G. Haskell
- Department of Veterans Affairs, Veterans Health Administration, Office of Women’s Health, 810 Vermont Ave NW, Washington, DC 20420, USA; (A.M.J.); (E.W.P.); (S.G.H.)
- VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, USA
- School of Medicine, Yale University, 333 Cedar St, New Haven, CT 06510, USA
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Relyea MR, Presseau C, Runels T, Humbert MM, Martino S, Brandt CA, Haskell SG, Portnoy GA. Understanding Veterans' intimate partner violence use and patterns of healthcare utilization. Health Serv Res 2023; 58:1198-1208. [PMID: 37452496 PMCID: PMC10622301 DOI: 10.1111/1475-6773.14201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. DATA SOURCES AND STUDY SETTING We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. STUDY DESIGN We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. DATA COLLECTION/EXTRACTION METHODS Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. PRINCIPAL FINDINGS Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. CONCLUSIONS Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.
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Affiliation(s)
- Mark R. Relyea
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Candice Presseau
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Tessa Runels
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | | | - Steve Martino
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Cynthia A. Brandt
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Sally G. Haskell
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
| | - Galina A. Portnoy
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of MedicineNew HavenConnecticutUSA
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Adjognon OL, Brady JE, Iverson KM, Stolzmann K, Dichter ME, Lew RA, Gerber MR, Portnoy GA, Iqbal S, Haskell SG, Bruce LAE, Miller CJ. Using the Matrixed Multiple Case Study approach to identify factors affecting the uptake of IPV screening programs following the use of implementation facilitation. Implement Sci Commun 2023; 4:145. [PMID: 37990345 PMCID: PMC10664531 DOI: 10.1186/s43058-023-00528-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Intimate partner violence (IPV) is a prevalent social determinant of health. The US Preventive Services Task Force recommends routine IPV screening of women, but uptake remains variable. The Veterans Health Administration (VHA) initiated implementation facilitation (IF) to support integration of IPV screening programs into primary care clinics. An evaluation of IF efforts showed variability in IPV screening rates across sites. The follow-up study presented here used a Matrixed Multiple Case Study (MMCS) approach to examine the multilevel factors impacting IPV screening program implementation across sites with varying levels of implementation success. METHODS This mixed methods study is part of a larger cluster randomized stepped wedge Hybrid-II program evaluation. In the larger trial, participating sites received 6 months of IF consisting of an external facilitator from VHA's Office of Women's Health working closely with an internal facilitator and key site personnel. Recognizing the heterogeneity in implementation outcomes across sites, the MMCS approach was used to enable interpretation of qualitative and quantitative data within and across sites to help contextualize the primary findings from the larger study. Qualitative data collection was guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and included interviews with key informants involved in IPV screening implementation at eight sites. Quantitative data on IPV screening uptake was derived from medical records and surveys completed by key personnel at the same eight sites to understand implementation facilitation activities. RESULTS Fifteen factors influencing IPV screening implementation spanning all four i-PARIHS domains were identified and categorized into three distinct categories: (1) factors with enabling influence across all sites, (2) factors deemed important to implementation success, and (3) factors differentiating sites with high/medium versus low implementation success. CONCLUSIONS Understanding the influencing factors across multi-level domains contributing to variable success of IPV screening implementation can inform the tailoring of IF efforts to promote spread and quality of screening. Implementation of IPV screening programs in primary care with IF should consider consistent engagement of internal facilitators with clinic staff involved in implementation, the resourcefulness of external facilitators, and appending resources to IPV screening tools to help key personnel address positive screens. TRIAL REGISTRATION ClinicalTrials.gov NCT04106193. Registered on September 26, 2019.
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Affiliation(s)
- Omonyêlé L Adjognon
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.
| | - Julianne E Brady
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Katherine M Iverson
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, PA, USA
- School of Social Work, Temple University, Philadelphia, PA, USA
| | - Robert A Lew
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
| | - Megan R Gerber
- Division of General Internal Medicine, Albany Medical College, Albany, NY, USA
- Albany Stratton VA Medical Center, Albany, NY, USA
| | - Galina A Portnoy
- Pain Research Informatics Multi-morbidity Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Samina Iqbal
- VA Palo Alto Healthcare System, Palo Alto, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sally G Haskell
- Pain Research Informatics Multi-morbidity Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Office of Women's Health, Department of Veterans Affairs, Washington, DC, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Le Ann E Bruce
- Intimate Partner Violence Assistance Program, Care Management and Social Work Services, Department of Veterans Affairs, Washington, DC, USA
- Department of Social Work, Western Kentucky University, Bowling Green, KY, USA
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, USA
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Gaffey AE, Rosman L, Lampert R, Yaggi HK, Haskell SG, Brandt CA, Enriquez AD, Mazzella AJ, Skanderson M, Burg MM. Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans. J Am Heart Assoc 2023; 12:e030331. [PMID: 37791503 PMCID: PMC10757545 DOI: 10.1161/jaha.123.030331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 10/05/2023]
Abstract
Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Internal Medicine (Cardiovascular Medicine)Yale School of MedicineNew HavenCTUSA
| | - Lindsey Rosman
- Division of Cardiology, Department of MedicineUniversity of North Carolina, Chapel HillChapel HillNCUSA
| | - Rachel Lampert
- Department of Internal Medicine (Cardiovascular Medicine)Yale School of MedicineNew HavenCTUSA
| | - Henry K. Yaggi
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine)Yale School of MedicineCTNew HavenUSA
| | - Sally G. Haskell
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Internal Medicine (General Medicine)Yale School of MedicineNew HavenCTUSA
| | - Cynthia A. Brandt
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Emergency MedicineYale School of MedicineNew HavenCTUSA
- Yale Center for Medical InformaticsYale School of MedicineNew HavenCTUSA
| | - Alan D. Enriquez
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Internal Medicine (Cardiovascular Medicine)Yale School of MedicineNew HavenCTUSA
| | - Anthony J. Mazzella
- Division of Cardiology, Department of MedicineUniversity of North Carolina, Chapel HillChapel HillNCUSA
| | | | - Matthew M. Burg
- VA Connecticut Healthcare SystemWest HavenCTUSA
- Department of Internal Medicine (Cardiovascular Medicine)Yale School of MedicineNew HavenCTUSA
- Department of AnesthesiologyYale School of MedicineNew HavenCTUSA
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Warren AR, Relyea MR, Gross GM, Eleazer JR, Goulet JL, Brandt CA, Haskell SG, Portnoy GA. Intimate partner violence among lesbian, gay, and bisexual veterans. Psychol Serv 2023:2024-00281-001. [PMID: 37602982 PMCID: PMC10879444 DOI: 10.1037/ser0000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
The present study describes intimate partner violence (IPV) perpetration and victimization alongside theoretically associated variables in a sample of lesbian, gay, and bisexual veterans. We conducted bivariate analyses (chi-square tests and independent t test) to examine whether the frequencies of IPV perpetration and victimization varied by demographic characteristics, military sexual trauma, alcohol use, and mental health symptoms. Out of the 69 lesbian, gay, and bisexual (LGB) veterans who answered the questions on IPV, 16 (23.2%) reported some form of IPV victimization in the past year, and 38 (55.1%) reported past-year perpetration. Among the 43 veterans who reported psychological IPV, roughly half (48.9%) reported bidirectional psychological IPV, 39.5% reported perpetration only, and 11.6% reported victimization only. LGB veterans who reported bidirectional psychological IPV in their relationships were younger and reported greater symptoms of posttraumatic stress disorder symptoms and depression. The results presented here call for universal screening of IPV perpetration and victimization to both accurately assess and ultimately intervene among all veterans. Inclusive interventions are needed for all genders and sexual orientations, specifically interventions that do not adhere to gendered assumptions of perpetrators and victims. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | | | | | - Jacob R Eleazer
- Department of Psychiatry and Psychology, Mayo Clinic Florida
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10
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Iverson KM, Stolzmann KL, Brady JE, Adjognon OL, Dichter ME, Lew RA, Gerber MR, Portnoy GA, Iqbal S, Haskell SG, Bruce LE, Miller CJ. Integrating Intimate Partner Violence Screening Programs in Primary Care: Results from a Hybrid-II Implementation-Effectiveness RCT. Am J Prev Med 2023; 65:251-260. [PMID: 37031032 PMCID: PMC10568536 DOI: 10.1016/j.amepre.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION The Veterans Health Administration initiated implementation facilitation to integrate intimate partner screening programs in primary care. This study investigates implementation facilitation's impact on implementation and clinical effectiveness outcomes. STUDY DESIGN A cluster randomized, stepped-wedge, hybrid-II implementation-effectiveness trial (January 2021-April 2022) was conducted amidst the COVID-19 pandemic. SETTING/PARTICIPANTS Implementation facilitation was applied at 9 Veterans Health Administration facilities, staged across 2 waves. Participants were all women receiving care at participating primary care clinics 3 months before (pre-implementation facilitation n=2,272) and 9 months after initiation of implementation facilitation (implementation facilitation n=5,149). INTERVENTION Implementation facilitation included an operations-funded external facilitator working for 6 months with a facility-funded internal facilitator from participating clinics. The pre-implementation facilitation period comprised implementation as usual in the Veterans Health Administration. MAIN OUTCOME MEASURES Primary outcomes were changes in (1) reach of intimate partner violence (IPV) screening programs among eligible women (i.e., those seen within participating clinics during the assessment period; implementation outcome) and (2) disclosure rates among screened women (effectiveness outcome). Secondary outcomes included disclosure rates among all eligible women and post-screening psychosocial service use. Administrative data were analyzed. RESULTS For primary outcomes, women seen during the implementation facilitation period were nearly 3 times more likely to be screened for IPV than women seen during the pre-implementation facilitation period (OR=2.70, 95% CI=2.46, 2.97). Women screened during the implementation facilitation period were not more likely to disclose IPV than those screened during the pre-implementation facilitation period (OR=1.14, 95% CI=0.86, 1.51). For secondary outcomes, owing to increased reach of screening during implementation facilitation, women seen during the implementation facilitation period were more likely to disclose IPV than those seen during the pre-implementation facilitation period (OR=2.09, 95% CI=1.52, 2.86). Women screened during implementation facilitation were more likely to use post-screening psychosocial services than those screened during pre-implementation facilitation (OR=1.29, 95% CI=1.06, 1.57). CONCLUSIONS Findings indicate that implementation facilitation may be a promising strategy for increasing the reach of IPV screening programs in primary care, thereby increasing IPV detection and strengthening connections to support services among the patient population. TRIAL REGISTRATION This study is registered at www. CLINICALTRIALS gov NCT04106193.
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Affiliation(s)
- Katherine M Iverson
- Women's Health Sciences Division, PTSD: National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts; Department of Psychiatry, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts; Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts.
| | - Kelly L Stolzmann
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Julianne E Brady
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Omonyêlé L Adjognon
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania; School of Social Work, Temple University, Philadelphia, Pennsylvania
| | - Robert A Lew
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) & CSP Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Megan R Gerber
- Division of General Internal Medicine, Department of Medicine, Albany Medical College, Albany, New York; Albany Stratton VA Medical Center, Albany, New York
| | - Galina A Portnoy
- Pain Research Informatics Multi-Morbidity Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Samina Iqbal
- VA Palo Alto Healthcare System, Palo Alto, California; Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sally G Haskell
- Pain Research Informatics Multi-Morbidity Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - LeAnn E Bruce
- Intimate Partner Violence Assistance Program, Care Management and Social Work, U.S. Department of Veterans Affairs, Washington, District of Columbia; Department of Social Work, Western Kentucky University, Bowling Green, Kentucky
| | - Christopher J Miller
- Center for Healthcare Organization & Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
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11
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Webermann AR, Relyea MR, Portnoy GA, Martino S, Brandt CA, Haskell SG. The Role of Unit and Interpersonal Support in Military Sexual Trauma and Posttraumatic Stress Disorder Symptoms. J Interpers Violence 2023; 38:9514-9535. [PMID: 37005795 DOI: 10.1177/08862605231165764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Military sexual trauma (MST) is strongly associated with posttraumatic stress disorder (PTSD). Among many potential factors explaining this association are unit and interpersonal support, which have been explored in few studies with veterans who have experienced MST. This project examines unit and interpersonal support as moderators and/or mediators of PTSD symptoms among post-9/11 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who experienced MST. MST, unit support, and interpersonal support variables were collected at Time 1 (T1; N = 1,150, 51.4% women), and PTSD symptoms 1 year later at Time 2 (T2; N = 825; 52.3% women). Given gender differences in endorsed MST, models with the full sample (men and women) and women only were examined, while controlling for covariates related to PTSD, and a path model was examined among women veterans. Mediation was supported in the full model and women-only models, with the combination of both mediators demonstrating the strongest mediation effects (full-model: β = .06, 95% confidence interval [CI] [0.03, 0.10], p < .001; women-only model: β = .07, [0.03, 0.14], p = .002). Among the women-only model, MST was negatively associated with unit support (β = -.23, [-0.33, -0.13], p < .001) and interpersonal support (β = -.16, [-0.27, -0.06], p = .002) and both support types were negatively associated with PTSD symptoms (unit support: β = -.13, [-0.24, -0.03], p = .014; interpersonal support: β = -.25, [-0.35, -0.15], p < .001). Moderation was not supported in the full model nor in the women-only model. Experiencing MST is associated with receiving less unit and/or interpersonal support, which in turn is associated with greater PTSD symptoms. More work is needed to understand and improve the impact of unit and community responses to MST on service members who experience MST.
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Affiliation(s)
- Aliya R Webermann
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Mark R Relyea
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Steve Martino
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
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12
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Ramsey CM, Gaffey AE, Brandt CA, Haskell SG, Masheb RM. Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior. Mil Med 2023; 188:921-927. [PMID: 35726626 DOI: 10.1093/milmed/usac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/28/2022] [Accepted: 05/27/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies. METHODS Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity. RESULTS Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity. CONCLUSIONS These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.
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Affiliation(s)
- Christine M Ramsey
- Mental Illness Research Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19130, USA
| | - Allison E Gaffey
- PRIME Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Cynthia A Brandt
- PRIME Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT 06510, USA
| | - Sally G Haskell
- PRIME Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Robin M Masheb
- PRIME Center of Innovation, VA Connecticut Healthcare System, West Haven, CT 06516, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT 06510, USA
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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Goulet JL, Warren AR, Workman TE, Skanderson M, Farmer MM, Gordon KS, Abel EA, Akgün KM, Bean-Mayberry B, Zeng-Treitler Q, Haderlein TP, Haskell SG, Bastian LA, Womack JA, Post LA, Hwang U, Brandt CA. Variation in firearm screening and access by LGBT status. Acad Emerg Med 2023; 30:420-423. [PMID: 36661348 DOI: 10.1111/acem.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Affiliation(s)
- Joseph L Goulet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Allison R Warren
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - T Elizabeth Workman
- Biomedical Informatics Center, The George Washington University, Washington, DC, USA
| | | | - Melissa M Farmer
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bevanne Bean-Mayberry
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, UCLA-David Geffen School of Medicine, Los Angeles, California, USA
| | - Qing Zeng-Treitler
- Biomedical Informatics Center, The George Washington University, Washington, DC, USA.,Washington DC VA Medical Center, Washington, DC, USA
| | - Taona P Haderlein
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Veterans Affairs, Veterans Emergency Management Evaluation Center (VEMEC), North Hills, California, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Julie A Womack
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Yale School of Nursing, VA Connecticut, West Haven, Connecticut, USA
| | - Lori A Post
- Northwestern University, Chicago, Illinois, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Cynthia A Brandt
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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16
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Dhruva SS, Dziura J, Bathulapalli H, Rosman L, Gaffey AE, Davis MB, Brandt CA, Haskell SG. Gender Differences in Guideline-Directed Medical Therapy for Cardiovascular Disease Among Young Veterans. J Gen Intern Med 2022; 37:806-815. [PMID: 36042086 PMCID: PMC9481764 DOI: 10.1007/s11606-022-07595-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes. OBJECTIVE To determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF. DESIGN Retrospective. PARTICIPANTS Veterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn. MAIN MEASURES Differences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors. KEY RESULTS Overall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p<0.001; and 43.7 vs. 45.4 years, p<0.02, respectively). In the 12 months following a diagnosis of incident CAD, the odds of a woman receiving a prescription for at least one CAD drug was 0.85 (95% confidence interval [CI], 0.68-1.08) compared to men. In the 12 months following a diagnosis of incident HF, the odds of a woman receiving at least one HF medication was 0.54 (95% CI, 0.37-0.79) compared to men. CONCLUSIONS Despite guideline recommendations, young women Veterans have approximately half the odds of being prescribed guideline-directed medical therapy within 1-year after a diagnosis of HF. These results highlight the need to develop targeted strategies to minimize gender disparities in CVD care to prevent adverse outcomes in this young and growing population.
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Affiliation(s)
- Sanket S Dhruva
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA. .,Section of Cardiology, Department of Medicine, UCSF School of Medicine, 4150 Clement St., Building 203, 111C, San Francisco, CA, 94121, USA.
| | - James Dziura
- Veterans Affairs Connecticut Healthcare System, West Haven, West Haven, USA.,Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Harini Bathulapalli
- Veterans Affairs Connecticut Healthcare System, West Haven, West Haven, USA.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lindsey Rosman
- Department of Medicine, Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Allison E Gaffey
- Veterans Affairs Connecticut Healthcare System, West Haven, West Haven, USA.,Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT, USA
| | - Melinda B Davis
- Veterans Affairs Ann Arbor Health System, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia A Brandt
- Veterans Affairs Connecticut Healthcare System, West Haven, West Haven, USA.,Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sally G Haskell
- Veterans Affairs Connecticut Healthcare System, West Haven, West Haven, USA.,Pain Research, Informatics, Multimorbidities and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.,Department of Internal Medicine (General), Yale School of Medicine, New Haven, CT, USA
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17
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Higgins DM, Han L, Kerns RD, Driscoll MA, Heapy AA, Skanderson M, Lisi AJ, Mattocks KM, Brandt C, Haskell SG. Risk factors associated with healthcare utilization for spine pain. Pain Med 2022; 23:1423-1433. [PMID: 34999899 DOI: 10.1093/pm/pnab351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study examined potential risk factors associated with healthcare utilization among patients with spine (i.e., neck and back) pain. METHODS A two-stage sampling approach examined spine pain episodes of care among veterans with a yearly outpatient visit for six consecutive years. Descriptive and bivariate statistics, followed by logistic regression analyses, examined baseline characteristics of veterans with new episodes of care who either continued or discontinued spine pain care. A multivariable logistic regression model examined correlates associated with seeking continued spine pain care. RESULTS Among 331,908 veterans without spine pain episodes of care during the two-year baseline observation period, 16.5% (n = 54,852) had a new episode of care during the following two-year observation period. Of those 54,852 veterans, 37,025 had an outpatient visit data during the final two-year follow-up period, with 53.7% (n = 19,865) evidencing continued spine pain care. Those with continued care were more likely to be overweight or obese, non-smokers, Army veterans, have higher education, and had higher rates of diagnoses of all medical and mental health conditions examined at baseline. Among several important findings, women had 13% lower odds of continued care during the final two-year observation period, OR 0.87 (0.81, 0.95). CONCLUSIONS A number of important demographics and clinical correlates were associated with increased likelihood of seeking new and continued episodes of care for spine pain; however, further examination of risk factors associated with healthcare utilization for spine pain is indicated.
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Affiliation(s)
- Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Ling Han
- Yale School of Public Health, New Haven, Connecticut
| | - Robert D Kerns
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Mary A Driscoll
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Alicia A Heapy
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | | | - Anthony J Lisi
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA.,University of Massachusetts Medical School, Worcester, MA
| | - Cynthia Brandt
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Sally G Haskell
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
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18
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Portnoy GA, Relyea MR, Presseau C, Orazietti S, Martino S, Brandt CA, Haskell SG. Longitudinal Analysis of Persistent Postconcussion Symptoms, Probable TBI, and Intimate Partner Violence Perpetration Among Veterans. J Head Trauma Rehabil 2022; 37:34-42. [PMID: 34985032 PMCID: PMC8740780 DOI: 10.1097/htr.0000000000000759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine veterans' intimate partner violence (IPV) perpetration following report of traumatic brain injury (TBI) and persistent postconcussion symptoms (PPCSs). SETTING Five Department of Veterans Affairs (VA) medical centers. PARTICIPANTS Veterans with nonmissing data on main measures, resulting in N = 1150 at baseline and N = 827 at follow-up. DESIGN Prospective cohort study with secondary data analysis of self-reported TBI, PPCSs, and IPV perpetration, controlling for common predictors of IPV, including binge drinking, marijuana use, pain intensity, and probable posttraumatic stress disorder. MAIN MEASURES VA TBI Screening Tool to assess for probable TBI and PPCSs; Conflict Tactics Scale-Revised (CTS-2S) to assess for IPV perpetration. RESULTS Almost half (48%) of participants reported IPV perpetration at follow-up. Both probable TBI and higher PPCSs at baseline were associated with overall IPV perpetration and more frequent IPV perpetration at follow-up. Only PPCSs significantly predicted IPV perpetration after controlling for common predictors of IPV perpetration. Neither probably TBI nor PPCSs predicted frequency of IPV perpetration. CONCLUSION When considered alongside common risk factors for IPV perpetration, PPCS was uniquely associated with the likelihood of IPV perpetration in this veteran sample. Given post-9/11 veterans' elevated risk for head injury, findings emphasize the distinctive value of PPCSs in understanding risk for IPV perpetration. We recommend increased assessment for PPCSs in clinical practice among veterans enrolled in VA care and highlight several important areas for future research and intervention development.
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Affiliation(s)
- Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut (Drs Portnoy, Relyea, Presseau, Martino, Brandt, and Haskell and Ms Orazietti); Yale University School of Medicine, New Haven, Connecticut (Drs Portnoy, Relyea, Presseau, Martino, Brandt, and Haskell)
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19
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Gaffey AE, Haskell SG, Brandt CA, Bastian LA, Meadows JL, Burg MM. Post-9/11 veterans' heart disease knowledge, self-perceived risk, and prevention beliefs and behaviors. Health Psychol 2021; 40:737-746. [PMID: 34780203 PMCID: PMC10691753 DOI: 10.1037/hea0001110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Veterans, including the growing number of women veterans, have a greater risk of heart disease than nonveterans, and the incidence of heart disease is increasing among the most recent veterans who participated in post-9/11 military conflicts. Investigating heart disease-related knowledge, self-perceived risk, and prevention beliefs and behavior among these veterans, and identifying potential differences in knowledge, risk, beliefs and behavior between men and women, may guide prevention strategies. METHOD Cross-sectional data from a nationwide survey of 1,141 (53% women) post-9/11 veterans were used to examine heart disease awareness and information-seeking, perceived risk and importance of heart disease risk factors, beliefs about traditional (e.g., weight, blood pressure) and nontraditional (e.g., stress, sleep) factors, and engagement in prevention behaviors. Differences between men and women were also tested, using t-tests, chi-square, and Fisher's exact tests. RESULTS Only one-third reported they felt very informed or sought information about heart disease, or that their providers had discussed heart disease with them. Although veterans generally believe that addressing traditional and nontraditional factors can reduce their risk of heart disease, far fewer endorsed the value of mental health treatment in prevention. Overall, women were slightly more knowledgeable about heart disease risk, and of behaviors that can lower this risk, but for both men and women, this knowledge did not translate to engaging in equivalent prevention behaviors. CONCLUSIONS Post-9/11 veterans, and potentially their providers, may each benefit from improved education regarding their risk of heart disease. Veterans may also require better, more personalized approaches to prevention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Sally G. Haskell
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (General), Yale School of Medicine
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Emergency Medicine, Yale School of Medicine
| | - Lori A. Bastian
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (General), Yale School of Medicine
| | - Judith L. Meadows
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Matthew M. Burg
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510
- Department of Anesthesiology, Yale School of Medicine
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20
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Gaffey AE, Rosman L, Haskell SG, Brandt CA, Sico JJ, Bastian LA, Dziura J, Burg MM. Abstract 48: Military Sexual Trauma Is Associated With Incident Hypertension In A 16-year Cohort Study Of 1.2 Million Young And Middle-aged Men And Women. Hypertension 2021. [DOI: 10.1161/hyp.78.suppl_1.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Exposure to traumatic events and the sequelae [e.g., posttraumatic stress disorder (PTSD) and poor health] are linked to incident cardiovascular disease (CVD) in military and community samples. Veterans, especially women, are 3-times as likely to experience sexual harassment and assault [military sexual trauma (MST)] compared to civilian populations. It is unknown if exposure to MST is independently associated with risk of incident hypertension.
Methods:
We conducted a retrospective analysis to assess the effect of MST on the risk of incident hypertension, defined as a medical record diagnosis, meeting clinical threshold based on blood pressure in vital sign records, or use of antihypertensive medication, in a cohort of 1,177,944 young and middle-aged veterans (mean age= 30.2 [SD:9.2], 12% women) using nationwide data from the Veterans Health Administration from 2001 to 2017. Time-varying multivariate Cox models were computed to estimate hypertension risk by MST status while sequentially adjusting for demographics, lifestyle factors, CVD comorbidities, and psychiatric disorders. Sensitivity analyses controlled for healthcare utilization based on the number of primary care visits over two years after military discharge.
Results:
During 16 years of follow-up (mean=9.6 years [SD:4.0]), 33,881 veterans screened positive for MST (65% women) and 307,332 patients were diagnosed with hypertension. The overall incidence rate of hypertension was 305.1 events per 1,000-person years. MST was associated with a 30% greater risk of hypertension in unadjusted models (hazard ratio [HR], 1.30 [95% CI, 1.28-1.33]) and remained significantly associated with hypertension in models that adjusted for demographics, lifestyle factors, CVD comorbidities, PTSD, anxiety, and depression (adjusted HR, 1.10 [95% CI, 1.08-1.12]. In sensitivity analyses, the effect of MST remained significant when controlling for healthcare utilization (HR, 1.11, [95% CI, 1.09-1.13]).
Conclusions:
In this large prospective cohort of young adults, MST was associated with an increased risk of hypertension after controlling for established risk factors. Further research is needed to determine if early identification of MST improves cardiovascular risk management.
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21
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Decker SE, Ramsey CM, Ronzitti S, Kerns RD, Driscoll MA, Dziura J, Skanderson M, Bathulapalli H, Brandt CA, Haskell SG, Goulet JL. Military sexual trauma and suicidal ideation in VHA-care-seeking OEF/OIF/OND veterans without mental health diagnosis or treatment. Psychiatry Res 2021; 303:114089. [PMID: 34247061 DOI: 10.1016/j.psychres.2021.114089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022]
Abstract
Sexual trauma is a suicide risk factor. While military sexual trauma (MST) is frequently associated with suicidal ideation (SI) in women and men veterans who served in recent conflicts, less is known about MST's relationship to SI in veterans who have no documented mental health concerns. Of the 1.1 million post-9/11 veterans enrolled in the Veterans Healthcare Administration (VHA) we examined 41,658 (12.3% women, 87.7% men) without evidence of mental health diagnosis or treatment and who were screened for MST and SI using the standard VHA clinical reminders between 2008 and 2013. Relative risk estimates were generated using separate models for women and men. MST was reported by 27.9% of women and 2.9% of men; SI by 14.7% and 16.5%, respectively. The adjusted relative risk of MST on SI was 1.65 (95% CI 1.35, 2.00) in women, and 1.49 (95% CI 1.26, 1.75) in men. In this sample of veterans without evidence of mental health diagnosis or treatment, MST was associated with a high risk of SI in both genders. Positive MST screening should prompt SI screening and risk management if indicated, and further study of barriers to mental healthcare among MST survivors at risk for suicide is warranted.
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Affiliation(s)
- Suzanne E Decker
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States; Mental Illness Research, Education, and Clinical Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States.
| | - Christine M Ramsey
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States; Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States
| | - Silvia Ronzitti
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Yale School of Medicine, New Haven, Connecticut, United States
| | - Robert D Kerns
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States; Department of Neurology, Yale School of Medicine, New Haven, Connecticut, United States; Department of Psychology, Yale University, New Haven, Connecticut, United States
| | - Mary A Driscoll
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States
| | - James Dziura
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Melissa Skanderson
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, United States
| | - Harini Bathulapalli
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Cynthia A Brandt
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Sally G Haskell
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States
| | - Joseph L Goulet
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States
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22
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Haskell SG, Han L, Abel EA, Bastian L, Driscoll M, Dziura J, Burg MM, Skanderson M, Brandt CA. Sex Differences in Use of a Clinical Complexity Measure to Predict Primary Care Utilization. J Womens Health (Larchmt) 2021; 31:71-78. [PMID: 34388023 DOI: 10.1089/jwh.2021.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The Veterans Affairs (VA)-developed Care Assessment Need (CAN) score, a risk-stratification tool used to identify complex high-risk patients and guide VA care coordination, was designed to predict hospitalization or death. Little is known about its utility in predicting primary care utilization or if gender differences in this metric are detectable. Our objective was to determine association of CAN score quintiles with high primary care visit (PCV) utilization among Veterans, the impact of adding reproductive health and psychosocial variables to the model and the difference between men and women Veterans. Methods: The sample included men and women from the post-9/11 cohort receiving VA care for at least 1 year, 2010-2017 (N = 665,379). PCV data for each year were collected from national Corporate Data Warehouse. A cumulative count ≥6 visits in a year was used as an indication for high PCV utilization in the analyses. Results: After accounting for potential confounding factors, women were associated with 42% higher odds of heavy PCV utilization (adjusted odds ratio: 1.42, 95% confidence interval: 1.37-1.46) than men. However, there was a significant interaction between sex and CAN quintiles (p < 0.001). After adjusting for all the covariates, CAN score quintiles appeared to have stronger associations and better predictive accuracy on the risk of 1-year heavy PCV utilization for men than for women. Conclusion: Further research is needed to understand sex differences in Veterans Health Administration clinical complexity measures and whether they can be successfully used to identify high-risk, high-utilizing women Veterans.
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Affiliation(s)
- Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erica A Abel
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Yale Center for Medical Informatics, New Haven, Connecticut, USA
| | - Lori Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mary Driscoll
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - James Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Matthew M Burg
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Yale Center for Medical Informatics, New Haven, Connecticut, USA
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23
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Minnier J, Rajeevan N, Gao L, Park B, Pyarajan S, Spellman P, Haskell SG, Brandt CA, Luoh SW. Polygenic Breast Cancer Risk for Women Veterans in the Million Veteran Program. JCO Precis Oncol 2021; 5:PO.20.00541. [PMID: 34381935 DOI: 10.1200/po.20.00541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/15/2021] [Accepted: 06/11/2021] [Indexed: 01/02/2023] Open
Abstract
Accurate breast cancer (BC) risk assessment allows personalized screening and prevention. Prospective validation of prediction models is required before clinical application. Here, we evaluate clinical- and genetic-based BC prediction models in a prospective cohort of women from the Million Veteran Program. MATERIALS AND METHODS Clinical BC risk prediction models were validated in combination with a genetic polygenic risk score of 313 (PRS313) single-nucleotide polymorphisms in genetic females without prior BC diagnosis (n = 35,130, mean age 49 years) with 30% non-Hispanic African ancestry (AA). Clinical risk models tested were Breast and Prostate Cancer Cohort Consortium, literature review, and Breast Cancer Risk Assessment Tool, and implemented with or without PRS313. Prediction accuracy and association with incident breast cancer was evaluated with area under the receiver operating characteristic curve (AUC), hazard ratios, and proportion with high absolute lifetime risk. RESULTS Three hundred thirty-eight participants developed incident breast cancers with a median follow-up of 3.9 years (2.5 cases/1,000 person-years), with 196 incident cases in women of European ancestry and 112 incident cases in AA women. Individualized Coherent Absolute Risk Estimator-literature review in combination with PRS313 had an AUC of 0.708 (95% CI, 0.659 to 0.758) in women with European or non-African ancestries and 0.625 (0.539 to 0.711) in AA women. Breast Cancer Risk Assessment Tool with PRS313 had an AUC of 0.695 (0.62 to 0.729) in European or non-AA and 0.675 (0.626 to 0.723) in AA women. Incorporation of PRS313 with clinical models improved prediction in European but not in AA women. Models estimated up to 9% of European and 18% of AA women with absolute lifetime risk > 20%. CONCLUSION Clinical and genetic BC risk models predict incident BC in a large prospective multiracial cohort; however, more work is needed to improve genetic risk estimation in AA women.
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Affiliation(s)
- Jessica Minnier
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
| | - Nallakkandi Rajeevan
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT.,Yale Center for Medical Informatics (YCMI), Yale School of Medicine, New Haven, CT
| | - Lina Gao
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
| | - Byung Park
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR.,Knight Cancer Institute, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
| | - Saiju Pyarajan
- VA Boston Healthcare System, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Paul Spellman
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, CT.,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Cynthia A Brandt
- Yale Center for Medical Informatics (YCMI), Yale School of Medicine, New Haven, CT.,VA Connecticut Healthcare System, West Haven, CT
| | - Shiuh-Wen Luoh
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR.,VA Portland Health Care System, Portland, OR
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24
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Masheb RM, Ramsey CM, Marsh AG, Decker SE, Maguen S, Brandt CA, Haskell SG. DSM-5 eating disorder prevalence, gender differences, and mental health associations in United States military veterans. Int J Eat Disord 2021; 54:1171-1180. [PMID: 33665848 DOI: 10.1002/eat.23501] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Little is known about prevalence estimates of new and revised DSM-5 eating disorders diagnoses in general, and especially among high-risk, underserved and diverse eating disorder populations. The aim of the current study was to determine prevalence, gender differences and correlates of DSM-5 eating disorders in veterans. METHOD Iraq and Afghanistan war era veterans (N = 1,121, 51.2% women) completed the Eating Disorder Diagnostic Scale-5 and validated measures of eating pathology and mental health between July 2014 and September 2019. RESULTS Overall more women than men (32.8% vs. 18.8%, p < .001) reported symptoms consistent with a DSM-5 eating disorder. Prevalence estimates (women vs. men) for the specific diagnoses were: Anorexia Nervosa (AN; 0.0% vs. 0.0%), Bulimia Nervosa (BN; 6.1% vs. 3.5%), Binge-Eating Disorder (BED; 4.4% vs. 2.9%), Atypical AN (AAN; 13.6% vs. 4.9%), Subclinical BN (0.0% vs. 0.2%), Subclinical BED (1.4% vs. 0.6%), Purging Disorder (2.1% vs. 0.7%), and Night Eating Syndrome (NES; 5.2% vs. 6.0%). Women were more likely to have BN or AAN, and there was no difference for BED or NES among genders. The eating disorder group had a higher mean BMI, and significantly greater eating pathology and mental health symptoms than the non-eating disorder group. DISCUSSION Approximately one-third of women, and one-fifth of men, reported symptoms consistent with a DSM-5 eating disorder diagnosis. These high prevalence estimates across genders, and associated mental health concerns, suggest an urgent need to better understand and address eating disorders in military and veteran populations.
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Affiliation(s)
- Robin M Masheb
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Christine M Ramsey
- Yale School of Medicine, New Haven, Connecticut, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Alison G Marsh
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Suzanne E Decker
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Shira Maguen
- University of California San Francisco Medical School, San Francisco, CA, USA.,San Francisco VA Health Care System, San Francisco, CA, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, New Haven, Connecticut, USA
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25
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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: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Masheb RM, Ramsey CM, Marsh AG, Snow JL, Brandt CA, Haskell SG. Atypical Anorexia Nervosa, not so atypical after all: Prevalence, correlates, and clinical severity among United States military Veterans. Eat Behav 2021; 41:101496. [PMID: 33711788 DOI: 10.1016/j.eatbeh.2021.101496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/11/2021] [Accepted: 02/22/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE DSM-5 Atypical Anorexia Nervosa (AAN), a new eating disorder diagnosis, presents similarly to Anorexia Nervosa (AN) in the absence of severe underweight. The prevalence of AAN and other DSM-5 eating disorders was estimated in a sample of Veterans. Sociodemographic, mental health, and eating behavior correlates were examined. METHOD Iraq and Afghanistan war era Veterans (N = 1137, 51.6% female) completed the Eating Disorder Diagnostic Scale-5 for probable AAN diagnosis, and validated measures of eating pathology and mental health, between February 2016 and October 2019. Multivariate analyses compared Veterans with AAN to those with and without any DSM-5 eating disorder. RESULTS Among completers, 13.6% of women and 4.9% of men in the sample met criteria for probable AAN and 19.2% of women and 13.9% of men for another eating disorder. Mean age was 41 years, and on average BMIs were classified as overweight (BMI = 28.8, SD = 5.6) despite being at least 10% lower than their lifetime highest weight. Two-thirds reported dietary restraint on more than half the days in the past month. On measures of mental health, the AAN group had worse functioning than the no eating disorder group, similar functioning to Veterans with Binge Eating Disorder (BED), and better functioning than Veterans with Bulimia Nervosa (BN). DISCUSSION Results support AAN as a highly prevalent and clinically significant diagnosis. Findings highlight the need to identify and address eating disorders, particularly other specified eating disorders not meeting criteria for AN, BN, or BED, in active military and Veteran, and other high-risk and underserved, populations.
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Affiliation(s)
- Robin M Masheb
- VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale School of Medicine, New Haven, CT, United States of America.
| | - Christine M Ramsey
- Yale School of Medicine, New Haven, CT, United States of America; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States of America
| | - Alison G Marsh
- VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Jennifer L Snow
- VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale School of Medicine, New Haven, CT, United States of America
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale School of Medicine, New Haven, CT, United States of America
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27
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Schwartz R, Frayne SM, Friedman S, Romodan Y, Berg E, Haskell SG, Shaw JG. Retaining VA Women's Health Primary Care Providers: Work Setting Matters. J Gen Intern Med 2021; 36:614-621. [PMID: 33063204 PMCID: PMC7947068 DOI: 10.1007/s11606-020-06285-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition. OBJECTIVE Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors. DESIGN This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression. PARTICIPANTS All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016. MAIN MEASURES The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week). KEY RESULTS Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86). CONCLUSIONS A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.
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Affiliation(s)
- Rachel Schwartz
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA. .,WellMD Center, Stanford University School of Medicine, Stanford, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Friedman
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Yasmin Romodan
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Sally G Haskell
- Women's Health Services, VA Central Office, Washington, DC, USA.,VA Connecticut Health Care System, West Haven, CT, USA.,Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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28
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Gaffey AE, Rosman L, Burg MM, Haskell SG, Brandt CA, Skanderson M, Dziura J, Sico JJ. Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study. Stroke 2021; 52:121-129. [PMID: 33297868 PMCID: PMC7770089 DOI: 10.1161/strokeaha.120.030379] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke. METHODS We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization. RESULTS During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke. CONCLUSIONS In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine),
Yale School of Medicine, New Haven, CT
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University
of North Carolina, Chapel Hill, Chapel Hill, NC
| | - Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine),
Yale School of Medicine, New Haven, CT
- Department of Anesthesiology, Yale School of Medicine
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale
School of Medicine
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, West Haven, CT
- Department of Emergency Medicine, Yale School of
Medicine
- Yale Center for Medical Informatics, Yale School of
Medicine
| | | | - James Dziura
- VA Connecticut Healthcare System, West Haven, CT
- Department of Emergency Medicine, Yale School of
Medicine
| | - Jason J. Sico
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale
School of Medicine
- Department of Neurology and Center for NeuroEpidemiological
and Clinical Neurological Research, Yale School of Medicine
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29
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Portnoy GA, Iverson KM, Haskell SG, Czarnogorski M, Gerber MR. A Multisite Quality Improvement Initiative to Enhance the Adoption of Screening Practices for Intimate Partner Violence Into Routine Primary Care for Women Veterans. Public Health Rep 2020; 136:52-60. [PMID: 33207128 PMCID: PMC7856383 DOI: 10.1177/0033354920966022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The Veterans Health Administration established comprehensive women's health clinics (CWHCs) to provide coordinated, high-quality primary care to women veterans. Intimate partner violence (IPV) is prevalent among women using these clinics. The Veterans Health Administration recommends screening women for IPV, yet screening uptake is low in CWHCs nationwide. We describe a multisite quality improvement initiative to enhance the adoption of IPV screening practices in the Veterans Health Administration's CWHCs. METHODS This quality improvement initiative, implemented in 2017-2018, included 4 steps in which we (1) conducted a baseline survey of screening practices at CWHCs throughout the United States; (2) selected and tailored evidence-based implementation strategies based on identified barriers and facilitators; (3) deployed multicomponent implementation support, targeting low-adopting facilities; and (4) conducted a follow-up survey to evaluate changes in IPV screening practices from baseline (winter 2017) to 1-year follow-up (winter 2018) using quantitative and qualitative analyses. RESULTS Responders from 62 CWHC sites provided information on IPV screening practices and barriers; 42 low-adopting sites were targeted for implementation support. At follow-up, responders provided information on IPV screening practices, perceived usefulness of implementation support strategies, and continued barriers. Among sites that responded to both surveys (n = 47), the number of sites that implemented recommended screening practices increased by 66.7%, from 15 at baseline to 25 at follow-up (P = .02). Emergent themes reflected barriers and facilitators for IPV screening implementation. CONCLUSIONS Improvement in IPV screening practices in CWHCs is a pivotal step toward enhancing care for women. Yet, even with numerous implementation supports, barriers to adoption persist at many sites. Findings on modifiable barriers and unique facilitators can inform next steps for increasing screening uptake.
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Affiliation(s)
- Galina A. Portnoy
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Katherine M. Iverson
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | | | - Megan R. Gerber
- Women’s Health Center, VA Boston Healthcare System, Boston, MA, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
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30
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Relyea MR, Portnoy GA, Klap R, Yano EM, Fodor A, Keith JA, Driver JA, Brandt CA, Haskell SG, Adams L. Evaluating Bystander Intervention Training to Address Patient Harassment at the Veterans Health Administration. Womens Health Issues 2020; 30:320-329. [PMID: 32830008 DOI: 10.1016/j.whi.2020.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 06/15/2020] [Accepted: 06/19/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.
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Affiliation(s)
- Mark R Relyea
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut.
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Ruth Klap
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; VA Women's Health Research Network (WHRN), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, UCLA Geffen School of Medicine, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; VA Women's Health Research Network (WHRN), VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Women's Health Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC
| | - Angie Fodor
- Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, CA
| | - Jessica A Keith
- Bay Pines VA Healthcare System, Bay Pines, Florida; University of Central Florida College of Medicine, Orlando, FL
| | - Jane A Driver
- New England Geriatric Research and Clinical Center, VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut
| | - Lynette Adams
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut; Women's Health Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC
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31
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Gross GM, Ronzitti S, Combellick JL, Decker SE, Mattocks KM, Hoff RA, Haskell SG, Brandt CA, Goulet JL. Sex Differences in Military Sexual Trauma and Severe Self-Directed Violence. Am J Prev Med 2020; 58:675-682. [PMID: 32037020 DOI: 10.1016/j.amepre.2019.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Previous research has demonstrated an association between military sexual trauma and risk for suicide; however, risk for self-directed violence such as suicide attempt or nonsuicidal self-injury following military sexual trauma is understudied. This study examines the relationship between military sexual trauma and serious self-directed violence resulting in hospitalization, as well as whether this relationship differs by sex. METHODS Participants were 750,176 Operations Enduring Freedom/Iraqi Freedom/New Dawn veterans who were enrolled in Veterans Health Administration care during the period of October 1, 2001-September 30, 2014 and who were screened for military sexual trauma. Data were analyzed in 2019. Bivariate analyses and Cox proportional hazards regression models were employed. RESULTS Women veterans were more likely to screen positive for military sexual trauma (21.33% vs 1.63%), and women and men were equally likely to experience serious self-directed violence (1.19% women vs 1.18% men). Controlling for demographic variables and psychiatric morbidity, military sexual trauma predicted serious self-directed violence for both men and women. Further, men with military sexual trauma were 15% less likely to experience self-directed violence compared with women with military sexual trauma (hazard ratio=0.85, 95% CI=0.74, 0.98). CONCLUSIONS Military sexual trauma is associated with risk for serious self-directed violence for both men and women veterans, and the relationship may be pronounced among women. Results underscore the importance of incorporating military sexual trauma into treatment and preventative efforts for self-directed violence.
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Affiliation(s)
- Georgina M Gross
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut.
| | - Silvia Ronzitti
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Joan L Combellick
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Suzanne E Decker
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Kristin M Mattocks
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
| | - Rani A Hoff
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Joseph L Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
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32
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Coleman JN, DeRycke EC, Bastian LA, Calhoun PS, Beckham JC, Kroll-Desrosiers AR, Haskell SG, Mattocks K, Brandt CA, Wilson SM. Predictors of prenatal smoking among US women veterans. J Health Psychol 2020; 26:2648-2655. [PMID: 32255376 DOI: 10.1177/1359105320913100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated prevalence and factors associated with prenatal smoking among US women veterans using cross-sectional data from a cohort study of veterans from recent wars utilizing Veterans Health Administration primary care (N = 6190). Among the participants, 747 (12.0%) were current smokers and 1039 (16.8%) were former smokers. Multivariable logistic regression indicated that White race, substance use disorder, and posttraumatic stress disorder were associated with increased likelihood of smoking during pregnancy. Conversely, being married and officer rank were associated with decreased likelihood of prenatal smoking. Findings suggest a need for empirical testing of interventions to address perinatal smoking, substance use, and mental health.
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Affiliation(s)
| | | | - Lori A Bastian
- VA Connecticut Healthcare System, USA.,Yale University School of Medicine, USA
| | - Patrick S Calhoun
- Duke University School of Medicine, USA.,Durham VA Health Care System, USA.,VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, USA
| | - Jean C Beckham
- Duke University School of Medicine, USA.,VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, USA
| | | | | | - Kristin Mattocks
- University of Massachusetts Medical School, USA.,VA Central Western Massachusetts Healthcare System, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, USA.,Yale University School of Medicine, USA
| | - Sarah M Wilson
- Duke University School of Medicine, USA.,Durham VA Health Care System, USA
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Dyer KE, Moreau JL, Finley E, Bean-Mayberry B, Farmer MM, Bernet D, Kress A, Lewis JL, Batuman FK, Haskell SG, Hamilton AB, Moin T. Tailoring an evidence-based lifestyle intervention to meet the needs of women Veterans with prediabetes. Women Health 2020; 60:748-762. [PMID: 31959089 DOI: 10.1080/03630242.2019.1710892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Prediabetes affects one-third of U.S. adults. Lifestyle change interventions, such as the Diabetes Prevention Program (DPP), can significantly lower type 2 diabetes risk, but little is known about how the DPP could be best adapted for women. This mixed-methods study assessed the impact of gender-tailoring and modality choice on DPP engagement among women Veterans with prediabetes. Participants were offered women-only groups and either in-person/peer-led or online modalities. Implementation outcomes were assessed using attendance logs, recruitment calls, and semi-structured interviews about patient preferences. Between June 2016 and March 2017, 119 women Veterans enrolled in the DPP (n = 51 in-person, n = 68 online). We conducted 22 interviews between August and September 2016 (n = 10 early-implementation) and March and July 2017 (n = 12 follow-up). Most interviewees preferred women-only groups, citing increased comfort, camaraderie, and mutual understanding of gender-specific barriers to lifestyle change. More women preferred online DPP, and those using this modality participated at higher rates. Most endorsed the importance of modality choice and were satisfied with their selection; however, selection was frequently based on participants' personal circumstances and access barriers and not on a "preferred choice" of two equally accessible options. Patient engagement and program reach can be expanded by tailoring the DPP for population-specific needs.
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Affiliation(s)
- Karen E Dyer
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Jessica L Moreau
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Erin Finley
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA.,Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT), South Texas Veterans Healthcare System , San Antonio, Texas, USA.,Departments of Medicine and Psychiatry, University of Texas Health Science Center , San Antonio, Texas, USA
| | - Bevanne Bean-Mayberry
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA.,UCLA David Geffen School of Medicine , Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Melissa M Farmer
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Dorothy Bernet
- VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Arthur Kress
- VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Jackie L Lewis
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Fatma K Batuman
- UCLA David Geffen School of Medicine , Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
| | - Sally G Haskell
- Women's Health Services, Veterans Health Administration , Washington, District of Columbia, USA.,VA Connecticut Healthcare System , West Haven, Connecticut, USA.,Yale University School of Medicine , New Haven, Connecticut, USA
| | - Alison B Hamilton
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA.,UCLA David Geffen School of Medicine , Los Angeles, California, USA
| | - Tannaz Moin
- VHA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System , Los Angeles, California, USA.,UCLA David Geffen School of Medicine , Los Angeles, California, USA.,VA Greater Los Angeles Healthcare System , Los Angeles, California, USA
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34
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Combellick JL, Bastian LA, Altemus M, Womack JA, Brandt CA, Smith A, Haskell SG. Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans. J Womens Health (Larchmt) 2020; 29:577-584. [PMID: 31905319 DOI: 10.1089/jwh.2019.7948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Maternal morbidity and mortality are key indicators of women's health status and quality of care. Maternal morbidity and mortality are high and rising in the United States. There has been no evaluation of severe maternal morbidity and mortality among veteran women, although population characteristics suggest that they may be at risk. This study aimed to evaluate a surveillance methodology at the U.S. Department of Veterans Affairs (VA) and describe the characteristics of women veterans who experienced severe maternal morbidity events. Materials and Methods: The study sample derived from a national sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who were enrolled for care at the VA. The surveillance methodology followed a recommended process of case identification and chart review following a standardized guide. Centers for Disease Control and Prevention (CDC) International Classification of Diseases codes for maternal morbidity were applied to billing, inpatient, and outpatient data for 9,829 pregnancies among 91,061 veteran women between January 1, 2014 and December 31, 2016. Descriptive statistics is reported. Results: One hundred twenty-seven pregnancies with severe maternal morbidity events were identified, 66 of which were confirmed after chart review. The positive predictive value of CDC indicators to identify cases was 0.52. High rates of mental health problems, obesity, rurality, maternal conditions, and racial discrepancies were noted among veterans who experienced severe maternal morbidity events. Conclusions: Severe maternal morbidity affects a significant number of veteran women. Systematic reporting of pregnancy outcomes and a multidisciplinary review committee would improve surveillance and case management at the VA. The VA is uniquely positioned to develop innovative comanagement strategies, especially in the area of perinatal mental health.
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Affiliation(s)
- Joan L Combellick
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Yale School of Nursing, Orange, Connecticut
| | - Lori A Bastian
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Margaret Altemus
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Julie A Womack
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Yale School of Nursing, Orange, Connecticut
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Yale School of Medicine, Center for Medical Informatics, New Haven, Connecticut
| | | | - Sally G Haskell
- VA Connecticut Healthcare System, PRIME Center (Pain, Research, Informatics, Multimorbidities, and Education), West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Ronzitti S, Loree AM, Potenza MN, Decker SE, Wilson SM, Abel EA, Haskell SG, Brandt CA, Goulet JL. Gender Differences in Suicide and Self-Directed Violence Risk Among Veterans With Post-traumatic Stress and Substance Use Disorders. Womens Health Issues 2019; 29 Suppl 1:S94-S102. [PMID: 31253249 DOI: 10.1016/j.whi.2019.04.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Veterans have a high prevalence of both post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), which are related to suicide risk. Exploring gender-related differences in suicidal behavior risk among this subgroup of veterans is important to improve prevention and treatment strategies. To date, few studies have explored these differences. METHODS The sample included 352,476 men and women veterans from the Women Veterans Cohort Study with a diagnosis of PTSD. First, we conducted analyses to assess gender-related differences in sociodemographic and clinical variables at baseline, as well as by suicidal behavior. Then, we conducted a series of Cox proportional hazards regression models to estimate the hazard ratios of engaging in self-directed violence (SDV) and dying by suicide by SUD status and gender, controlling for potential confounders. RESULTS Adjusted analyses showed that, among veterans with PTSD, the presence of a SUD significantly increased the risk of SDV and death by suicide. Women with PTSD had a decreased risk of dying by suicide compared with men. No gender-related difference was observed for SDV. SUD increased the risk of SDV behavior in both women and men but increased the risk of dying by suicide only among men. CONCLUSIONS Our findings revealed gender-related differences in SDV and suicide among veterans with a PTSD diagnosis with or without a SUD. Our study, along with the increasing numbers of women serving in the military, stresses the need to conduct gender-based analyses to help improve prevention and treatment strategies.
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Affiliation(s)
- Silvia Ronzitti
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, New Haven, Connecticut.
| | - Amy M Loree
- VA Connecticut Healthcare System, West Haven, Connecticut; Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, Michigan
| | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut; Department of Neuroscience, Child Study Center, Connecticut Mental Health Center, New Haven, Connecticut; Connecticut Council on Problem Gambling, Yale School of Medicine, New Haven, Connecticut
| | | | - Sarah M Wilson
- VA Center for Health Services Research in Primary Care, Durham, North Carolina; Duke University School of Medicine, Durham, North Carolina; Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Erica A Abel
- VA Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
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36
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Whitehead AM, Maher NH, Goldstein K, Bean-Mayberry B, Duvernoy C, Davis M, Safdar B, Saechao F, Lee J, Frayne SM, Haskell SG. Sex Differences in Veterans' Cardiovascular Health. J Womens Health (Larchmt) 2019; 28:1418-1427. [DOI: 10.1089/jwh.2018.7228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Alison M. Whitehead
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
| | - Nancy H. Maher
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
| | - Karen Goldstein
- Durham VA and Duke University School of Medicine, Durham, North Carolina
| | - Bevanne Bean-Mayberry
- VA Greater Los Angeles and Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Claire Duvernoy
- VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, Michigan
| | - Melinda Davis
- Department of Medicine, Cardiology Clinic, University of Michigan, Ann Arbor, Michigan
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Fay Saechao
- VA Health Services Research and Development (HSR&D) Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Jimmy Lee
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Susan M. Frayne
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Sally G. Haskell
- Department of Veterans Affairs, Central Office, Washington, District of Columbia
- VA Connecticut Healthcare System and Yale University, West Haven, Connecticut
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37
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Lynch SM, Wilson SM, DeRycke EC, Driscoll MA, Becker WC, Goulet JL, Kerns RD, Mattocks KM, Brandt CA, Bathulapalli H, Skanderson M, Haskell SG, Bastian LA. Impact of Cigarette Smoking Status on Pain Intensity Among Veterans With and Without Hepatitis C. Pain Med 2019; 19:S5-S11. [PMID: 30203017 DOI: 10.1093/pm/pny146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Objective Chronic pain is a significant problem in patients living with hepatitis C virus (HCV). Tobacco smoking is an independent risk factor for high pain intensity among veterans. This study aims to examine the independent associations with smoking and HCV on pain intensity, as well as the interaction of smoking and HCV on the association with pain intensity. Design/Particpants Cross-sectional analysis of a cohort study of veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who had at least one visit to a Veterans Health Administration (VHA) primary care clinic between 2001 and 2014. Methods HCV was identified using ICD-9 codes from electronic medical records (EMRs). Pain intensity, reported on a 0-10 numeric rating scale, was categorized as none/mild (0-3) and moderate/severe (4-10). Results Among 654,841 OEF/OIF/OND veterans (median age [interquartile range] = 26 [23-36] years), 2,942 (0.4%) were diagnosed with HCV. Overall, moderate/severe pain intensity was reported in 36% of veterans, and 37% were current smokers. The adjusted odds of reporting moderate/severe pain intensity were 1.23 times higher (95% confidence interval [CI] = 1.14-1.33) for those with HCV and 1.26 times higher (95% CI = 1.25-1.28) for current smokers. In the interaction model, there was a significant Smoking Status × HCV interaction (P = 0.03). Among veterans with HCV, smoking had a significantly larger association with moderate/severe pain (adjusted odds ratio [OR] = 1.50, P < 0.001) than among veterans without HCV (adjusted OR = 1.26, P < 0.001). Conclusions We found that current smoking is more strongly linked to pain intensity among veterans with HCV. Further investigations are needed to explore the impact of smoking status on pain and to promote smoking cessation and pain management in veterans with HCV.
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Affiliation(s)
- Shaina M Lynch
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah M Wilson
- Center for Health Services Research in Primary Care, Durham VA Health Care System, Durham, North Carolina.,Duke University School of Medicine, Durham, North Carolina
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Psychiatry
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System West Haven, Connecticut.,Department of Internal Medicine
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38
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Combellick JL, Dziura J, Portnoy GA, Mattocks KM, Brandt CA, Haskell SG. Trauma and Sexual Risk: Do Men and Women Veterans Differ? Womens Health Issues 2019; 29 Suppl 1:S74-S82. [PMID: 31253246 DOI: 10.1016/j.whi.2019.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 04/19/2019] [Accepted: 04/22/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Trauma has been associated with risky sexual behavior in diverse populations. However, little is known about this association among men and women veterans. This study hypothesized that 1) a history of trauma would be associated with risky sexual behavior among men and women veterans, 2) interpersonal trauma would predict risky sexual behavior among women, whereas noninterpersonal trauma would predict risky sexual behavior among men, and 3) military-related trauma would constitute additional risk. Using data from 567 women and 524 men veterans enrolled at the Veterans Health Administration, this study investigated the association between trauma-related experiences and risky sexual behavior in the last 12 months. Risk and protective factors that have been frequently associated with sexual behavior in previous research were also included in the model. METHODS This study was drawn from the Women Veterans Cohort Study, a national survey of veterans. Bivariate and multivariate analyses were performed after multiple imputation for missing data. RESULTS Predictive factors associated with risky sexual behavior differed between men and women veterans. Among women, childhood sexual victimization and intimate partner violence were associated with risky sexual behavior. Among men, binge drinking was the single significant risk factor. Military exposures were not significantly associated with risky sexual behavior in either men or women. CONCLUSIONS This study lays the groundwork for theory-generating research into the psychological underpinnings of noted associations and underscores the importance of integrated health services to address the range of issues affecting sexual behavior and related health outcomes.
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Affiliation(s)
- Joan L Combellick
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Midwifery, Yale School of Nursing, Orange, Connecticut.
| | - James Dziura
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Northampton, Massachusetts; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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39
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Gaffey AE, Redeker NS, Haskell SG, Brandt CA, Burg MM. 0341 Men and Women Veterans’ Military Experiences and Associated Risk of Insomnia. Sleep 2019. [DOI: 10.1093/sleep/zsz067.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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40
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Portnoy GA, Relyea MR, Decker S, Shamaskin-Garroway A, Driscoll M, Brandt CA, Haskell SG. Understanding Gender Differences in Resilience Among Veterans: Trauma History and Social Ecology. J Trauma Stress 2018; 31:845-855. [PMID: 30431668 DOI: 10.1002/jts.22341] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 11/10/2022]
Abstract
A social-ecological framework for resilience underscores the importance of conceptualizing individuals embedded within their context when evaluating a person's vulnerability and adaptation to stress. Despite a high level of trauma exposure, most veterans exhibit psychological resilience following a traumatic event. Interpersonal trauma is associated with poorer psychological outcomes than noninterpersonal trauma and is experienced more frequently across the lifespan by women as compared to men. In the present study, we examined gender differences in trauma exposure, resilience, and protective factors among veterans. Participants included 665 veterans who completed a baseline survey assessing traumatic events; 544 veterans (81.8%) completed a 1-year follow-up survey assessing resilience, combat exposure, deployment social support, deployment preparedness, and military sexual trauma (MST). Principal component analyses revealed the Traumatic Life Events Questionnaire categorized into four meaningful components: sexual abuse, interpersonal violence, stranger violence, and accidents/unexpected trauma. Women reported greater exposure to sexual abuse, d = 0.76; interpersonal violence, d = 0.31; and MST, Cramer's V = 0.54; men reported greater exposure to stranger violence, accidents/unexpected trauma, and combat exposure, ds = 0.24-0.55. Compared to women, men also reported greater social support during deployment, d = 0.46. Hierarchical linear regression indicated that men's resilience scores were higher than women's, β = .10, p = .032, yet this association was no longer significant once we accounted for trauma type, β = .07, p = .197. Results indicate that trauma type is central to resilience and suggest one must consider the social-ecological context that can promote or inhibit resilient processes.
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Affiliation(s)
- Galina A Portnoy
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Department of Psychiatry, New Haven, Connecticut, USA
| | - Mark R Relyea
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Center for Medical Informatics, New Haven, Connecticut, USA
| | - Suzanne Decker
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Department of Psychiatry, New Haven, Connecticut, USA
| | - Andrea Shamaskin-Garroway
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Mary Driscoll
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Department of Psychiatry, New Haven, Connecticut, USA
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Emergency Medicine, Center for Medical Informatics, New Haven, Connecticut, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut, USA
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Affiliation(s)
- Megan R Gerber
- Women's Health Program , VA Boston Healthcare System, 150 South Huntington Avenue, PC 11/WHC, Boston, MA, 02130, USA.
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Kristina M Bogdan
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
| | - Sally G Haskell
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Erica R Scioli
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
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42
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Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. Pain Medicine 2018; 19:S54-S60. [PMID: 30203014 DOI: 10.1093/pm/pny114] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Anthony J Lisi
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts
- School of Medicine, Boston University, Boston, Massachusetts
| | - Todd Kawecki
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Christine Ramsey
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher B Ruser
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
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Driscoll MA, Higgins D, Shamaskin-Garroway A, Burger A, Buta E, Goulet JL, Heapy A, Kerns RD, Brandt CA, Haskell SG. Examining Gender as a Correlate of Self-Reported Pain Treatment Use Among Recent Service Veterans with Deployment-Related Musculoskeletal Disorders. Pain Med 2018; 18:1767-1777. [PMID: 28379576 DOI: 10.1093/pm/pnx023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Women veterans with chronic pain utilize health care with greater frequency than their male counterparts. However, little is known about gender differences in the use of specialty pain care in this population. This investigation examined gender differences in self-reported use of opioids, interventional pain treatments, rehabilitation therapies, and complementary and integrative health (CIH) services for chronic pain treatment both within and outside of the Veterans Health Administration in a sample of veterans who served in support of recent conflicts. Methods Participants included 325 veterans (54% women) who completed a baseline survey as part of the Women Veterans Cohort Study and reported deployment-related musculoskeletal conditions and chronic pain. Measures included self-reported use of pain treatment modalities, pain severity, self-rated health, access to specialty care, disability status, and presence of a mental health condition. Results Men were more likely to report a persistent deployment-related musculoskeletal condition but were no more likely than women to report chronic pain. Overall, 21% of the sample reported using opioids, 27% used interventional strategies, 59% used rehabilitation therapies, and 57% used CIH services. No significant gender differences in use of any pain treatment modality were observed. Conclusions Use of pain specialty services was common among men and women, particularly rehabilitative and CIH services. There were no gender differences in the self-reported use of different modalities. These results are inconsistent with documented gender differences in pain care. They encourage further examination of gender differences in preferences and other individual difference variables as predictors of specialty pain care utilization.
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Affiliation(s)
- Mary A Driscoll
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Diana Higgins
- VA Boston Healthcare System, Jamaica Plain, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Andrea Shamaskin-Garroway
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | | | - Eugenia Buta
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Joseph L Goulet
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Alicia Heapy
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Cynthia A Brandt
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
| | - Sally G Haskell
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities, and Education (PRIME), A Health Services Research and Development Center of Innovation, West Haven, Connecticut.,Yale School of Medicine, New Haven, Connecticut
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44
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Edmond SN, Becker WC, Driscoll MA, Decker SE, Higgins DM, Mattocks KM, Kerns RD, Haskell SG. Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey. J Gen Intern Med 2018; 33:54-60. [PMID: 29633141 PMCID: PMC5902341 DOI: 10.1007/s11606-018-4322-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite strong evidence for the effectiveness of non-pharmacological pain treatment modalities (NPMs), little is known about the prevalence or correlates of NPM use. OBJECTIVE This study examined rates and correlates of NPM use in a sample of veterans who served during recent conflicts. DESIGN We examined rates and demographic and clinical correlates of self-reported NPM use (operationalized as psychological/behavioral therapies, exercise/movement therapies, and manual therapies). We calculated descriptive statistics and examined bivariate associations and multivariable associations using logistic regression. PARTICIPANTS Participants were 460 veterans endorsing pain lasting ≥ 3 months who completed the baseline survey of the Women Veterans Cohort Study (response rate 7.7%. MAIN MEASURES Outcome was self-reported use of NPMs in the past 12 months. KEY RESULTS Veterans were 33.76 years old (SD = 10.72), 56.3% female, and 80.2% White. Regarding NPM use, 22.6% reported using psychological/behavioral, 50.9% used exercise/movement and 51.7% used manual therapies. Veterans with a college degree (vs. no degree; OR = 2.51, 95% CI = 1.46, 4.30, p = 0.001) or those with worse mental health symptoms (OR = 2.88, 95% CI = 2.11, 3.93, p < 0.001) were more likely to use psychological/behavioral therapies. Veterans who were female (OR = 0.63, 95% CI = 0.43, 0.93, p = 0.02) or who used non-opioid pain medications (OR = 1.82, 95% CI = 1.146, 2.84, p = 0.009) were more likely to use exercise/movement therapies. Veterans who were non-White (OR = 0.57, 95% CI = 0.5, 0.94, p = 0.03), with greater educational attainment (OR = 2.11, 95% CI = 1.42, 3.15, p < 0.001), or who used non-opioid pain medication (OR = 1.71, 95% CI = 1.09, 2.68, p = 0.02) were more likely to use manual therapies. CONCLUSIONS Results identified demographic and clinical characteristics among different NPMs, which may indicate differences in veteran treatment preferences or provider referral patterns. Further study of provider referral patterns and veteran treatment preferences is needed to inform interventions to increase NPM utilization. Research is also need to identify demographic and clinical correlates of clinical outcomes related to NPM use.
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Affiliation(s)
- Sara N Edmond
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Suzanne E Decker
- Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
- New England Mental Illness Research Education and Clinical Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Diana M Higgins
- Anesthesiology, Critical Care, and Pain Medicine Service, VA Boston Healthcare System, 150 S. Huntington Avenue, Jamaica Plain, MA, 02130, USA
- Department of Psychiatry, Boston University School of Medicine, 72 E. Concord Street, Boston, MA, 02118, USA
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, 421 N Main Street, Leeds, MA, 01053, USA
- Quantitative Health Sciences and Psychiatry, University of Massachusetts Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
- Departments of Neurology and Psychology, Yale University, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center/11ACSLG, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
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Bastian LA, Driscoll MA, Heapy AA, Becker WC, Goulet JL, Kerns RD, DeRycke EC, Perez E, Lynch SM, Mattocks K, Kroll-Desrosiers AR, Brandt CA, Skanderson M, Bathulapalli H, Haskell SG. Cigarette Smoking Status and Receipt of an Opioid Prescription Among Veterans of Recent Wars. Pain Med 2018; 18:1089-1097. [PMID: 27659441 DOI: 10.1093/pm/pnw223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective Cigarette smokers seeking treatment for chronic pain have higher rates of opioid use than nonsmokers. This study aims to examine whether veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who smoke are more likely to receive an opioid prescription than nonsmokers, adjusting for current pain intensity. Design Cross-sectional analysis of a cohort study of OEF/OIF/OND veterans who had at least one visit to a Veterans Health Administration primary care clinic between 2001 and 2012. Methods Smoking status was defined as current, former, and never. Current pain intensity (+/- 30 days of smoking status), based on the 0-10 numeric rating scale, was categorized as no pain/mild (0-3) and moderate/severe (4-10). Opioid receipt was defined as at least one prescription filled +/- 30 days of smoking status. Results We identified 406,954 OEF/OIF/OND veterans: The mean age was 30 years, 12.5% were women (n = 50,988), 66.3% reported no pain or mild pain intensity, 33.7% reported moderate or severe pain intensity, 37.2% were current smokers, and 16% were former smokers. Overall, 33,960 (8.3%) veterans received one or more opioid prescription. Current smoking (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.52-1.61) and former smoking (OR = 1.27, 95% CI = 1.22-1.32) were associated with a higher likelihood of receipt of an opioid prescription compared with never smoking, after controlling for other covariates. Conclusions We found an association between smoking status and receipt of an opioid prescription. The effect was stronger for current smokers than former smokers, highlighting the need to determine whether smoking cessation is associated with a reduction in opioid use among veterans.
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Affiliation(s)
- Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Alicia A Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - William C Becker
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Robert D Kerns
- Yale University School of Medicine, New Haven, Connecticut
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Elliottnell Perez
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Shaina M Lynch
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts.,University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Yale University School of Medicine, New Haven, Connecticut
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Shamaskin-Garroway AM, Knobf MT, Adams LJ, Haskell SG. "I Think It's Pretty Much the Same, as It Should Be": Perspectives of Inpatient Care Among Women Veterans. Qual Health Res 2018; 28:600-609. [PMID: 29231129 DOI: 10.1177/1049732317746380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The purpose of this study was to gain a deeper understanding of the inpatient hospitalization experience for women veterans through in-depth interviews. Women veterans who were admitted for inpatient care on medical units within a university-affiliated VA hospital were invited to participate in a semistructured interview that inquired about their hospital experience, interactions with medical providers, and how being a woman veteran might affect this experience. Interviews were transcribed verbatim and analyzed using constant comparative method until thematic saturation was achieved ( n = 25). Three themes, (a) Being a woman and a veteran: Intersecting identities, (b) Expecting equality and equity, and (c) Defining woman-centered inpatient care described the unique perspective and context for Veterans Health Administration (VHA) health care of women veterans. These findings provide insight and guidance to clinical practice and care delivery for women veterans, including training and interpersonal approaches medical providers can take to improve the hospital experience for women.
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Affiliation(s)
- Andrea M Shamaskin-Garroway
- 1 School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
- 2 VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - M Tish Knobf
- 3 Yale School of Nursing, Orange, Connecticut, USA
| | - Lynette J Adams
- 2 VA Connecticut Healthcare System, West Haven, Connecticut, USA
- 4 Yale School of Medicine, New Haven, Connecticut, USA
| | - Sally G Haskell
- 2 VA Connecticut Healthcare System, West Haven, Connecticut, USA
- 4 Yale School of Medicine, New Haven, Connecticut, USA
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Moreau JL, Cordasco KM, Young AS, Oishi SM, Rose DE, Canelo I, Yano EM, Haskell SG, Hamilton AB. The Use of Telemental Health to Meet the Mental Health Needs of Women Using Department of Veterans Affairs Services. Womens Health Issues 2018; 28:181-187. [DOI: 10.1016/j.whi.2017.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/27/2017] [Accepted: 12/11/2017] [Indexed: 01/01/2023]
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Hamilton AB, Farmer MM, Moin T, Finley EP, Lang AJ, Oishi SM, Huynh AK, Zuchowski J, Haskell SG, Bean-Mayberry B. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research. Implement Sci 2017; 12:127. [PMID: 29116022 PMCID: PMC5678767 DOI: 10.1186/s13012-017-0658-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/20/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Enhancing Mental and Physical health of Women through Engagement and Retention or EMPOWER program represents a partnership with the US Department of Veterans Health Administration (VA) Health Service Research and Development investigators and the VA Office of Women's Health, National Center for Disease Prevention and Health Promotion, Primary Care-Mental Health Integration Program Office, Women's Mental Health Services, and the Office of Patient Centered Care and Cultural Transformation. EMPOWER includes three projects designed to improve women Veterans' engagement and retention in evidence-based care for high-priority health conditions, i.e., prediabetes, cardiovascular, and mental health. METHODS/DESIGN The three proposed projects will be conducted in VA primary care clinics that serve women Veterans including general primary care and women's health clinics. The first project is a 1-year quality improvement project targeting diabetes prevention. Two multi-site research implementation studies will focus on cardiovascular risk prevention and collaborative care to address women Veterans' mental health treatment needs respectively. All projects will use the evidence-based Replicating Effective Programs (REP) implementation strategy, enhanced with multi-stakeholder engagement and complexity theory. Mixed methods implementation evaluations will focus on investigating primary implementation outcomes of adoption, acceptability, feasibility, and reach. Program-wide organizational-, provider-, and patient-level measures and tools will be utilized to enhance synergy, productivity, and impact. Both implementation research studies will use a non-randomized stepped wedge design. DISCUSSION EMPOWER represents a coherent program of women's health implementation research and quality improvement that utilizes cross-project implementation strategies and evaluation methodology. The EMPOWER Quality Enhancement Research Initiative (QUERI) will constitute a major milestone for realizing women Veterans' engagement and empowerment in the VA system. EMPOWER QUERI will be conducted in close partnership with key VA operations partners, such as the VA Office of Women's Health, to disseminate and spread the programs nationally. TRIAL REGISTRATION The two implementation research studies described in this protocol have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans: Trial registration NCT02991534 , registered 9 December 2016. Implementation of Tailored Collaborative Care for Women Veterans: Trial registration NCT02950961 , registered 21 October 2016.
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Affiliation(s)
- Alison B. Hamilton
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Melissa M. Farmer
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
| | - Tannaz Moin
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Erin P. Finley
- South Texas Veterans Health Care, San Antonio, TX USA
- University of Texas Health Science Center, San Antonio, TX USA
| | - Ariel J. Lang
- VA San Diego Healthcare System, San Diego, CA USA
- University of California San Diego, San Diego, CA USA
| | - Sabine M. Oishi
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
| | - Alexis K. Huynh
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
| | - Jessica Zuchowski
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT USA
- Yale School of Medicine, Yale University, New Haven, CT USA
| | - Bevanne Bean-Mayberry
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA USA
- Veterans Affairs Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, California USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
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49
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Gerber MR, King MW, Iverson KM, Pineles SL, Haskell SG. Association Between Mental Health Burden and Coronary Artery Disease in U.S. Women Veterans Over 45: A National Cross-Sectional Study. J Womens Health (Larchmt) 2017; 27:238-244. [PMID: 28981382 DOI: 10.1089/jwh.2017.6328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The women Veteran population accessing Veterans Health Administration (VA) care has grown rapidly. Women Veterans exhibit high rates of mental health conditions that increase coronary artery disease (CAD) risk; however, the relationship between specific conditions and increasing mental health burden to CAD in this population is unknown. MATERIALS AND METHODS Using VA National Patient Care Data for 2009, we identified women Veterans over 45 (N = 157,195). Logistic regression models examined different mental health diagnoses and increasing mental health burden (number of diagnostic clusters) as predictors of CAD. RESULTS CAD prevalence was 4.16%, and 36% of women Veterans were current smokers. Depression exhibited the strongest association with CAD (odds ratio [OR] 1.60, 95% confidence interval [CI] [1.50-1.71]), similar to that of current smoking (OR 1.68 [1.58-1.78]). Controlling for demographic variables, smoking, diabetes, and obesity, each additional mental health diagnosis increased the odds of CAD by 44%. CONCLUSIONS Women Veterans over age 45 accessing VA care exhibited a high degree of mental health burden, which is associated with elevated odds of CAD; those with depression alone had 60% higher odds of CAD. For women Veterans using VA, mental health diagnoses may act as CAD risk factors that are potentially modifiable. Novel interventions in primary care and mental health are needed to address heart disease in this growing and aging population.
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Affiliation(s)
- Megan R Gerber
- 1 Women's Health, VA Boston Healthcare System , Jamaica Plain, Massachusetts.,2 Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine , Boston, Massachusetts
| | - Matthew W King
- 3 National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Jamaica Plain, Massachusetts.,4 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts
| | - Katherine M Iverson
- 3 National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Jamaica Plain, Massachusetts.,4 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts
| | - Suzanne L Pineles
- 3 National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Jamaica Plain, Massachusetts.,4 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts
| | - Sally G Haskell
- 5 Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System , West Haven, Connecticut.,6 Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine , New Haven, Connecticut
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50
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Patel KV, Cochrane BB, Turk DC, Bastian LA, Haskell SG, Woods NF, Zaslavsky O, Wallace RB, Kerns RD. Association of Pain With Physical Function, Depressive Symptoms, Fatigue, and Sleep Quality Among Veteran and non-Veteran Postmenopausal Women. Gerontologist 2017; 56 Suppl 1:S91-101. [PMID: 26768395 DOI: 10.1093/geront/gnv670] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF STUDY To characterize the prevalence and longitudinal effects of pain in older Veteran and non-Veteran women. DESIGN AND METHODS Data on 144,956 participants in the Women's Health Initiative were analyzed. At baseline, Veteran status, pain severity, and pain interference with activity were assessed. Outcomes of physical function, depressive symptoms, fatigue, and sleep quality were reported at baseline by all study participants and longitudinally on two follow-up occasions (3 years and 13-18 years after baseline) in the observational study participants (n = 87,336). RESULTS At baseline, a total of 3,687 (2.5%) had a history of military service and 22,813 (15.8%) reported that pain limited their activity level moderately to extremely during the past 4 weeks. Prevalence of pain interference did not differ in Veterans and non-Veterans (16.8% and 15.7%, respectively; p= .09). At baseline, women with moderate-to-extreme pain interference had substantially worse physical function and greater symptoms of depression, fatigue, and insomnia than those with less pain (p < .001 for all comparisons), adjusting for several social, behavioral, and health related factors. There were no significant military service by pain interference interactions for any of the outcomes (p > .2), indicating that the effect of pain interference on outcomes at baseline did not vary between Veterans and non-Veterans. Moderate-to-extreme pain interference was associated with a greater rate of decline in physical function over time (p < .001) and higher incidence of limited physical functioning (p < .001), but these effects did not vary by Veteran status. Similar results were observed with pain severity as the exposure variable. IMPLICATIONS As the Veteran population ages and the number of women exposed to combat operations grows, there will be an increased need for health care services that address not only pain severity and interference but also other disabling comorbid symptoms.
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Affiliation(s)
- Kushang V Patel
- Center for Pain Research on Impact, Measurement, and Effectiveness, Department of Anesthesiology and Pain Medicine, University of Washington, Seatle. Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle.
| | - Barbara B Cochrane
- de Tornyay Center for Healthy Aging, University of Washington School of Nursing, Seattle. Fred Hutchinson Cancer Research Center, Public Health Sciences, Seattle, Washington
| | - Dennis C Turk
- Center for Pain Research on Impact, Measurement, and Effectiveness, Department of Anesthesiology and Pain Medicine, University of Washington, Seatle
| | - Lori A Bastian
- VA Connecticut, Newington. Division of General Internal Medicine, University of Connecticut, Farmington
| | - Sally G Haskell
- VA Office of Patient Care, Women's Health Services, Washington, District of Columbia. VA Connecticut Health Care System, West Haven. Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Nancy F Woods
- de Tornyay Center for Healthy Aging, University of Washington School of Nursing, Seattle. Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle
| | - Oleg Zaslavsky
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle
| | | | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven. Department of Psychiatry and Department of Neurology, Yale University, New Haven, Connecticut
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