Sexual Health Assessment Is Vital to Whole Health Models of Care.

Sexual health is the state of well-being regarding sexuality. Sexual health is highly valued and associated with overall health. Overall health and well-being are more than the absence of disease or dysfunction. Health care systems adopting whole health models of care need to incorporate a holistic assessment of sexual health. This includes assessing patients' sexual orientation and gender identity (SOGI). If health systems, including but not limited to the Veterans Health Administration (VHA), incorporate sexual health into whole health they could enhance preventive care, promote healthy sexual functioning, and optimize overall health and well-being. Assessing sexual health can give providers important information about a patient's health, well-being, and health goals. Sexual concerns or dysfunction may also signal undiagnosed health conditions. Additionally, collecting SOGI information as part of a sexual health assessment would allow providers to address problems that drive disparities for lesbian, gay, bisexual, transgender, queer, and similar minority (LGBTQ+) populations. Health care providers do not routinely assess sexual health in clinical practice. One barrier is a gap in communication between patients and providers. Providers cite beliefs that patients will bring up sexual concerns themselves or might be offended by discussing sexual health. Patients often report an expectation that providers will bring up sexual health and being comfortable discussing sexual health with their providers. Within the VHA, the lack of a sexual health template within the electronic health record (EHR) adds an additional barrier. The VHA's transition toward whole health and updates to its EHR provide unique opportunities to integrate sexual health assessment into routine care. We highlight system modifications to address this within the VHA. These examples may be helpful for other health care systems interested in moving toward whole health. It will be vital for health care systems integrating a whole health approach to develop both practical and educational interventions to address the communication gap. These interventions will need to target both providers and patients in health care systems that transition to a whole health model of care, not just the VHA. Both the communication gap between providers and patients, and the lack of support within some EHR systems for sexual health assessment are barriers to assessing sexual health in primary care clinics. Routine sexual health assessment would benefit patient well-being and present an opportunity to address health disparities for LGBTQ+ populations. Health care systems (ie, both the VHA and other systems) can overcome these barriers by implementing educational interventions and updating their EHRs and back-end data structures. VHA's expertise in developing and implementing health education interventions and EHR-based quality improvements may help inform interventions beyond VHA.

Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act.

BACKGROUND: Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN). OBJECTIVES: To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract. RESEARCH DESIGN: We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN. RESULTS: The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans. CONCLUSIONS: VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care.

BACKGROUND: Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care. OBJECTIVE: To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide. RESEARCH DESIGN: Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care. RESULTS: Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites. CONCLUSIONS: There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy.

BACKGROUND: Researchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans. METHODS: This study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy. RESULTS: Lifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11-2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19-2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15-2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36-0.96), younger age (OR, 0.95; 95% CI, 0.91-0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37-0.84) were associated with a decreased likelihood of actual VA service use during pregnancy. CONCLUSIONS: Results emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.

Disparities in Breastfeeding Among Military Veterans.

BACKGROUND: Although breastfeeding is a major public health priority and provides numerous benefits, women veterans encounter many barriers to initiating and sustaining breastfeeding. Women veterans are a growing population with unique health care needs related to exposures and injuries experienced during military service. These military experiences are linked to health diagnoses known to impact postpartum health behaviors, such as breastfeeding. RESEARCH AIM: The aim of this study was to identify factors associated with breastfeeding at 4 weeks postpartum among women veterans. METHODS: We used 2016-to-2018 survey data from women veterans (N = 420), interviewed before and after delivery, who were enrolled in maternity care coordination at a national sample of Veterans Health Administration facilities. Using the social ecological model, logistic regression was employed to explore the relationship between breastfeeding at least 4 weeks and postpartum and maternal/infant characteristics, interpersonal dynamics, community influences, and system factors. RESULTS: The rate of breastfeeding at 4 weeks postpartum was 78.6% among this sample of veterans. Self-employed participants were 2.8 times more likely to breastfeed than those who were employed outside the home. Participants who had been deployed at any point in their military career were twice as likely to breastfeed compared with those who never deployed. In this study sample, race independently predicted lower rates of breastfeeding, with African American participants being 48% less likely to breastfeed as compared with white participants. CONCLUSION: Our analysis suggests significant racial disparities in breastfeeding within veteran populations utilizing Veterans Health Administration, despite access to multiple sources of support from both the Veterans Health Administration and the community.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Factors Impacting Perceived Access to Early Prenatal Care among Pregnant Veterans Enrolled in the Department of Veterans Affairs.

BACKGROUND: Despite the relatively recent Department of Veterans Affairs (VA) policy advances in providing care for veterans and their infants during the perinatal period, little information exists regarding access to prenatal care for women veterans. Currently, VA medical centers do not provide onsite pregnancy care for veterans, but pay for care from community obstetricians through the Veterans Choice Program (VCP) and related non-VA care programs. The VCP is subcontracted to two large contractors, Health Net and TriWest, to assist the VA in administering the VCP. To date, no studies have evaluated women's perceived access to prenatal care under the VCP. OBJECTIVE: The purpose of this study was to understand pregnant veterans' perceived access to community prenatal care through the VCP. DESIGN: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study is a longitudinal, prospective multisite observational cohort study of pregnant and postpartum veterans at 15 VA facilities nationwide. Telephone surveys were conducted with women veterans at 20 weeks of pregnancy. We used multivariable logistic regression to examine the odds of receiving care early enough adjusted for these key factors. Measures included perceived access to early prenatal care by race, age, marital status, history of mental health conditions, urban/rural residence, and the VCP contractor (Health Net vs. TriWest). RESULTS: Overall, 519 women veterans completed the baseline pregnancy survey. A sizeable proportion of participants reported a history of mental health conditions, including depression (56.7%), anxiety disorder (45.5%), and posttraumatic stress disorder (40.5%). White veterans were more likely to report perceived timely access to prenatal care than minority veterans (66% vs. 52%; p = .0038). Veterans receiving care at Health Net facilities were more likely to report receiving prenatal care as early as desired in comparison to veterans at TriWest facilities (adjusted odds ratio, 0.48; 95% CI, 0.32-0.73), whereas veterans with a history of depression were 1.7 times more likely to report perceived delays in desired prenatal care compared with veterans without a history of depression (adjusted odds ratio, 1.65; 95% CI, 1.08-2.53). CONCLUSIONS: We found that nearly one-third of women reported problems receiving early prenatal care as soon as they would have liked. Women with histories of depression and racial minorities may require additional maternity care coordination services to ensure they receive timely prenatal care. Community-based provider networks under the VCP should continue to be expanded so that pregnant veterans are able to access high-quality prenatal care in a timely manner.

Examining Women Veteran's Experiences, Perceptions, and Challenges With the Veterans Choice Program.

BACKGROUND: The Veterans Choice Program (VCP) was launched in 2014 to address the growing concerns about the timeliness and quality of Veterans Health Administration (VHA) care. Given that many sex-specific health services, such as mammography and maternity care, are not routinely provided in all VHA facilities, women Veterans may disproportionately rely on VCP care. Understanding the provision and coordination of VCP care is crucial in order to ensure that care is not fragmented across the 2 health care systems. OBJECTIVES: The main objective of this study was to understand women Veterans' experiences, perceptions, and challenges with VCP care. DESIGN: This study was a semistructured interview with 148 women at 13 VHA facilities nationwide. RESULTS: Four major themes emerged: (1) eligibility information for the VCP was limited and confusing; (2) women experienced difficulty scheduling VCP appointments; (3) VCP care results were not shared with women Veterans or their VHA providers in a timely manner; and (4) concerns with unpaid VCP bills were common. CONCLUSIONS: Our study highlights challenges women experienced with VCP care, and the need for improved care coordination. An ideal care coordination system would be the one in which all Veterans' non-Veteran Affairs care, including scheduling, follow-up, communication with community providers, coordination of services, and transition back to Veteran Affairs care is ensured.

Implementing and Evaluating a Telephone-Based Centralized Maternity Care Coordination Program for Pregnant Veterans in the Department of Veterans Affairs.

PURPOSE: The purpose of this study was to develop and evaluate a comprehensive, telephonic maternity care coordination (MCC) program for all pregnant veterans enrolled for care at New England Department of Veterans Affairs (VA) facilities that comprise the Veterans Integrated Service Network 1. RESEARCH DESIGN: Telephone interviews were conducted with postpartum women veterans who had participated in the MCC program during their pregnancies. The program evaluation instrument assessed satisfaction and use of MCC services, prenatal education classes, and infant and maternal outcomes (e.g., newborn birthweight, insurance status, maternal depression) using both closed-ended and open-ended questions. RESULTS: A substantial majority (95%) of women enrolled in the MCC program expressed satisfaction with the services they received in the program. Women were most satisfied with help understanding VA maternity benefits and acquiring VA services and equipment, such as breast pumps and pregnancy-related medications. More than one-third of women noted their infants had experienced health problems since delivery, including neonatal intensive care unit hospitalizations. A majority of women planned to return to VA care in the future. CONCLUSIONS: Our findings suggest that MCC services play an important role for women veterans as they navigate both VA and non-VA care systems. MCC staff members coordinated maternity, medical, and mental health care services for women veterans. Additionally, by maintaining contact with the veteran during the postpartum period, MCC staff were able to assess the health of the mother and the infant, and refer women and their infants to medical and psychosocial services in the community as needed.

The Veterans Choice Act: A Qualitative Examination of Rapid Policy Implementation in the Department of Veterans Affairs.

BACKGROUND: Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 [Veterans Choice Act (VCA)] to improve access to timely, high-quality health care for Veterans. Although Congress mandated that VCA must begin within 90 days of passage of the legislation, no guidelines were provided in the legislation to ensure that Veterans had access to an adequate number of community providers across different specialties of care or distinct geographic areas, including rural areas of the country. OBJECTIVE: To examine VCA policy implementation across a sampling of Veterans Health Administration (VHA) Medical Centers. RESEARCH DESIGN: We conducted a qualitative study of 43 VHA staff and providers by conducting in-person interviews at 5 VA medical centers in the West, South, and Midwest United States. Interview questions focused on perceptions and experiences with VCA and challenges related to implementation for VHA staff and providers. RESULTS: We identified 3 major themes to guide description of choice implementation: (1) VCA implemented too rapidly with inadequate preparation; (2) community provider networks insufficiently developed; and (3) communication and scheduling problems with subcontractors may lead to further delays in care. CONCLUSIONS: Our evaluation suggests that VCA was implemented far too rapidly, with little consideration given to the adequacy of community provider networks available to provide care to Veterans. Given the challenges we have highlighted in VCA implementation, it is imperative that the VHA continue to develop care coordination systems that will allow the Veterans to receive seamless care in the community.

Eating Behaviors: Prevalence, Psychiatric Comorbidity, and Associations With Body Mass Index Among Male and Female Iraq and Afghanistan Veterans.

OBJECTIVE: There is a dearth of research examining eating behaviors, such as binge eating, among male and female veterans. The present study evaluated the prevalence of self-reported eating problems as well as associations with body mass index and psychiatric disorders among male and female Iraq and Afghanistan veterans. METHODS: Participants were 298 male and 364 female veterans (M = 33.3 ± 10.6 years old) from the Women Veterans Cohort Study, a study of male and female veterans enrolled for Veterans Affairs care in New England or Indiana. Veterans self-reported on emotion- and stress-related eating, eating disorder diagnoses, and disordered eating behaviors. Diagnoses of post-traumatic stress disorder, major depressive disorder, and alcohol abuse were obtained from administrative records. RESULTS: Female veterans reported higher rates of eating problems than did their male counterparts. Women and men who engage in disordered eating had higher rates of post-traumatic stress disorder and major depressive disorder, and women who engage in disordered eating had greater rates of alcohol abuse than did female veterans without eating disordered behaviors. CONCLUSIONS: Disordered eating may be a significant issue among Iraq and Afghanistan veterans, and veterans with eating problems are more likely to have comorbid mental health conditions that further increase their health risks.

Five-year trends in women veterans' use of VA maternity benefits, 2008-2012.

BACKGROUND: An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time. OBJECTIVE: The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits. DESIGN: We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012. PARTICIPANTS: We included pregnant veterans using VHA maternity benefits for delivery. MAIN MEASURES: Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator. KEY RESULTS: During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran). CONCLUSIONS: Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.

Understanding Health-Care Needs of Sexual and Gender Minority Veterans: How Targeted Research and Policy Can Improve Health.

Given the size of the patient population of the Veterans Health Administration (VHA), it is likely the largest single provider of health care for sexual and gender minority (SGM) individuals in the United States, including lesbian, gay, bisexual, and transgender persons. However, current VHA demographic data-collection strategies limit the understanding of how many SGM veterans there are, thereby making a population-based understanding of the health needs of SGM veterans receiving care in VHA difficult. In this article, we summarize the emergent research findings about SGM veterans and the first initiatives that have been implemented by VHA to promote quality care. Though the research on SGM veterans is in its infancy, it suggests that SGM veterans share some of the health risks noted in veterans generally and also risks associated with SGM status. Some promising resiliency factors have also been identified. These findings have implications for both VHA and non-VHA systems in the treatment of SGM veterans. However, more research on the unique needs of SGM veterans is needed to fully understand their health risks and resiliencies in addition to health-care utilization patterns.

Women veterans' reproductive health preferences and experiences: a focus group analysis.

OBJECTIVE: Although women veterans are seeking care at the Veterans Administration (VA) in record numbers, there is little information regarding women veterans' experiences and preferences for reproductive health care services. We sought to characterize women veterans' experiences with, and preferences for, reproductive health services in the VA. METHODS: We conducted five focus groups with a total of 25 participants using a semistructured interview guide to elicit women veterans' experiences and preferences with reproductive health care. Women veterans' utilizing VA health care at two VA facilities who responded to advertisements were selected on a first-come basis to participate in the study. We analyzed transcripts of these audio-recorded sessions using the constant comparative method of grounded theory. RESULTS: Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women's clinics for comprehensive medical care; 2) Women veterans have had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. CONCLUSION: As the VA continues to tailor its services to women veterans, attention should be given to women's reproductive health care needs.

Drug toxicity, HIV progression, or comorbidity of aging: does tipranavir use increase the risk of intracranial hemorrhage?

The US Food and Drug Administration has issued a warning that tipranavir may be associated with increased risk of intracranial hemorrhage. We studied 2 large cohorts to estimate the background rate of intracranial hemorrhage and compared it with rates reported among persons who had been exposed to tipranavir.