Risk of Parkinson Disease Among Service Members at Marine Corps Base Camp Lejeune.

Importance: An increased risk of Parkinson disease (PD) has been associated with exposure to the solvent trichloroethylene (TCE), but data are limited. Millions of people in the US and worldwide are exposed to TCE in air, food, and water. Objective: To test whether the risk of PD is higher in veterans who served at Marine Corps Base Camp Lejeune, whose water supply was contaminated with TCE and other volatile organic compounds (VOCs), compared with veterans who did not serve on that base. Design, Setting, and Participants: This population-based cohort study examined the risk for PD among all Marines and Navy personnel who resided at Camp Lejeune, North Carolina (contaminated water) (n = 172 128), or Camp Pendleton, California (uncontaminated water) (n = 168 361), for at least 3 months between 1975 and 1985, with follow-up from January 1, 1997, until February 17, 2021. Veterans Health Administration and Medicare databases were searched for International Classification of Diseases diagnostic codes for PD or other forms of parkinsonism and related medications and for diagnostic codes indicative of prodromal disease. Parkinson disease diagnoses were confirmed by medical record review. Exposures: Water supplies at Camp Lejeune were contaminated with several VOCs. Levels were highest for TCE, with monthly median values greater than 70-fold the permissible amount. Main Outcome and Measures: Risk of PD in former residents of Camp Lejeune relative to residents of Camp Pendleton. In those without PD or another form of parkinsonism, the risk of being diagnosed with features of prodromal PD were assessed individually and cumulatively using likelihood ratio tests. Results: Health data were available for 158 122 veterans (46.4%). Demographic characteristics were similar between Camp Lejeune (5.3% women, 94.7% men; mean [SD] attained age of 59.64 [4.43] years; 29.7% Black, 6.0% Hispanic, 67.6% White; and 2.7% other race and ethnicity) and Camp Pendleton (3.8% women, 96.2% men; mean [SD] age, 59.80 [4.62] years; 23.4% Black, 9.4% Hispanic, 71.1% White, and 5.5% other race and ethnicity). A total of 430 veterans had PD, with 279 from Camp Lejeune (prevalence, 0.33%) and 151 from Camp Pendleton (prevalence, 0.21%). In multivariable models, Camp Lejeune veterans had a 70% higher risk of PD (odds ratio, 1.70; 95% CI, 1.39-2.07; P < .001). No excess risk was found for other forms of neurodegenerative parkinsonism. Camp Lejeune veterans also had a significantly increased risk of prodromal PD diagnoses, including tremor, anxiety, and erectile dysfunction, and higher cumulative prodromal risk scores. Conclusions and Relevance: The study's findings suggest that the risk of PD is higher in persons exposed to TCE and other VOCs in water 4 decades ago. Millions worldwide have been and continue to be exposed to this ubiquitous environmental contaminant.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time.

BACKGROUND: Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE: To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN: Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS: 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES: Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS: Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS: After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

BACKGROUND: The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES: The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN: This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS: Veterans receiving primary care services paid for by the VA. MEASURES: Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS: There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION: As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

Experiences with the Veterans' Choice Program.

BACKGROUND: To address concerns about Veterans' access to care at US Department of Veterans Affairs (VA) healthcare facilities, the Veterans Access, Choice, and Accountability Act was enacted to facilitate Veterans' access to care in non-VA settings, resulting in the "Veterans Choice Program" (VCP). OBJECTIVES: To assess the characteristics of Veterans who used or planned to use the VCP, reasons for using or planning to use the VCP, and experiences with the VCP. DESIGN: Mixed-methods. SUBJECTS: After sampling Veterans in the Midwest census region receiving care at VA healthcare facilities, we included 4521 Veterans in the analyses. Of these, 60 Veterans participated in semi-structured qualitative interviews. APPROACH: Quantitative data were derived from VA's administrative and clinical data and a survey of Veterans including Veteran characteristics and self-reported use of VCP. Associations between Veterans' characteristics and use or planned use of the VCP were assessed using logistic regression analysis. Interview data were analyzed using thematic analysis. KEY RESULTS: Veterans with a higher odds of reporting use or intended use of the VCP were women, lived further distances from VA facilities, or had worse health status than other Veterans (P ≤ 0.01). Key themes included positive experiences with the VCP (timeliness of care, location of care, access to services, scheduling improvements, and coverage of services), and negative experiences with the VCP (complicated scheduling processes, inconveniently located appointments, delays securing appointments, billing confusion, and communication breakdowns). DISCUSSION: Our findings suggest that Veterans value access to care close to their home and care that addresses the needs of women and Veterans with poor health status. The Mission Act was passed in June 2018 to restructure the VCP and consolidate community care into a single program, continuing VA's commitment to support access to community care into the future.

Healthcare Utilization and Costs for Patients With Parkinson's Disease After Deep Brain Stimulation.

OBJECTIVE: To compare the complications, healthcare utilization and costs following DBS or medical management for patients with Parkinson's disease (PD). METHODS: We examined healthcare utilization and costs for up to 5 years between veterans with DBS and those with medical management for PD. Veterans who received DBS between 2007 and 2013 were matched with veterans who received medical management using propensity score approaches. Healthcare utilization and costs were obtained from national VA and Medicare data sources and compared using procedures to adjust for potential differences in length of follow-up. RESULTS: We identified 611 veterans who had received DBS and a matched group of 611 veterans who did not undergo DBS. Among DBS patients, 59% had the electrodes and generator implanted during separate admissions. After 5 years of follow-up, average total healthcare costs, including DBS procedures and complications, were $77,131 (95% confidence interval: $66,095-$88,168; P < 0.001) higher per person for patients who received DBS ($162,489) than patients who received medical management ($85,358). In contrast, excluding the costs of the DBS procedures and complications, average total costs were not significantly different between patients who received DBS and patients who received medical management after 5 years of follow-up. CONCLUSIONS: Healthcare costs over 5 years were higher for veterans who received DBS. These higher healthcare costs may reflect the costs of DBS procedures and any follow-up required plus greater surveillance by healthcare professionals following DBS as well as unobserved differences in the patients who received medical management or DBS.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors.

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients' perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10-50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07-2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers' likelihood of exploring context but not contextualizing care. Information about patients' life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Cost of deep brain stimulation for the treatment of Parkinson's disease by surgical stimulation sites.

OBJECTIVE: To assess costs and effectiveness of deep brain stimulation (DBS) of the internal globus pallidum (GPi) versus subthalamic nucleus (STN) from the provider and societal perspectives for Parkinson's disease (PD) patients in a multicenter randomized trial. METHODS: All costs from randomization to 36 months were included. Costs were from Department of Veterans Affairs (VA) and Medicare databases and clinical trial data. Quality adjusted life years (QALYs) were from Quality of Well Being questionnaires. RESULTS: Provider costs were similar for the 144 GPi and 130 STN patients (GPi: $138,044 vs. STN: $131,822; difference = $6,222, 95% confidence interval [CI]: -$42,125 to $45,343). Societal costs were also similar (GPi: $171,061 vs. STN: $167,706; difference = $3,356, 95% CI: -$57,371 to $60,294). The GPi patients had nonsignificantly more QALYs. CONCLUSIONS: The QALYs and costs were similar; the level of uncertainty given the sample size suggests that these factors should not direct treatment or resource allocation decisions in selecting or making available either procedure for eligible PD patients.

Improving the quality of telephone-delivered health care: a national quality improvement transformation initiative.

BACKGROUND: Many Veterans Affairs (VA) primary care (PC) patients prefer telephone-delivered care to other health care delivery modalities. OBJECTIVE: To evaluate PC patients' telephone experiences and outcomes before and after a national telephone transformation quality improvement (QI) collaborative. METHODS: Cross-sectional surveys were conducted pre- and post-collaborative. We used bivariate analyses to assess differences in pre/post outcomes and multivariate regression to identify variables associated with patients' perceptions of poor quality care. RESULTS: Patients from 13 VA facilities participated (n = 730; pre-intervention = 314, post-intervention = 416); most of them were males (90%) with a mean age of 62 years. After the collaborative (versus pre-collaborative), few experienced transfers (52% versus 62%, P = 0.0006) and most reported timely call answer (88% versus 80%, P = 0.003). Improvements in staff understanding why patients were calling and providing needed medical information were also found. There were measurable improvements in patient satisfaction (87% versus 82% very/mostly satisfied, P = 0.04) and perceived quality of telephone care (85% versus 78% excellent/good quality, P = 0.01) post- collaborative. The proportion of veterans who reported delayed care due to telephone access issues decreased from 41% to 15% after the collaborative, P < 0.0001. Perceptions of poor quality care were higher when calls were for urgent care needs did not result in receipt of needed information and included a transfer or untimely answer. CONCLUSIONS: The QI collaborative led to improvements in timeliness of answering calls, patient satisfaction and perceptions of high-quality telephone care and fewer reports of health care delays. Barriers to optimal telephone care 'quality' include untimely answer, transfers, non-receipt of needed information and urgent care needs.

Medication acquisition across systems of care and patient-provider communication among older veterans.

PURPOSE: The results of a survey assessing Medicare Part D enrollment, the use of pharmacotherapies for chronic diseases, and other medication-use issues in a population of elderly military veterans are presented. METHODS: Medicare-eligible (i.e., ≥65 years of age) patients with documented recent service use at a single Veterans Affairs (VA) medical center were targeted for a mail survey. Women were oversampled (20%) to ensure an adequate sample size; the sample was weighted to adjust for this oversampling. Usable survey data were received from 458 survey respondents. RESULTS: Nearly all respondents (93.2%) reported having one or more chronic conditions; of those, 93.3% reported regular use of multiple drug therapies, and 30.1% reported using medications prescribed by both VA and non-VA providers for the same chronic condition. About half of the survey respondents reported at least one office visit with a non-VA physician during the previous year, and 55.8% reported obtaining medications from non-VA pharmacies. More than half (54.1%) of the respondents reported non-VA medication coverage, with 21.2% indicating they were enrolled in Medicare Part D. Among the respondents who reported obtaining medications from non-VA pharmacies, substantial proportions reported discussing those medications with VA physicians never (38.4%) or infrequently (15.7%). CONCLUSION: Although large proportions of Medicare-eligible veterans take multiple medications and use non-VA health care services and pharmacies, many do not discuss medications obtained outside the VA system with VA physicians, suggesting that increased efforts to enhance provider-patient communication and medication reconciliation across VA and non-VA systems of care may be warranted.

Unannounced standardized patient assessment of the roter interaction analysis system: the challenge of measuring patient-centered communication.

BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.

Parkinson's disease medication use and costs following deep brain stimulation.

The costs of treating Parkinson's disease (PD) are significant. Medication reductions usually occur following deep brain stimulation (DBS), but less is known about the relative costs of DBS targets, the globus pallidum (GPi) or the subthalamic nucleus (STN). This article reports medication costs between best medical therapy (BMT) and DBS over 6 months postintervention and by DBS target over 36 months postsurgery. Prescription use and costs for patients (n = 161) with advanced PD from a multisite randomized trial of BMT and DBS were examined overall and by drug category. Medication adjustment occurred at the discretion of the neurologists. PD medications were extracted from the Department of Veterans Affairs Decision Support System database. Levodopa equivalents (LEDD) were significantly lower for DBS than for BMT patients at 6 months (1101 vs 1398 mg; P = .005), but costs were similar (US$1750 vs US$1589; P = .55). LEDD decreased following GPi and STN DBS (1395-1161 mg, P = .014; and 1347-891 mg, P < .0001, respectively) in the first 6 months, but was lower for STN than for GPi over 36 months following DBS (P = .03). Total PD medication costs per 6-month intervals decreased over 36 months (P < .0001), but did not differ by target (P = .50) in the mixed-model analysis. However, cumulative medication costs over 36 months were lower for the STN than for GPi patients. PD medication use and costs decreased following DBS in either target over 36 months, but cumulative costs were less for STN than for GPi.

Participant Retention in the Veterans Health Administration's MOVE! Weight management program, 2010.

INTRODUCTION: Participant retention is a frequent concern in structured weight-management programs. Although research has explored participant characteristics influencing retention, little attention has been given to the influence of program characteristics. The objective of this study was to examine how program characteristics relate to participant retention in the Veterans Health Administration's weight-management program, MOVE! METHODS: We conducted semistructured interviews with coordinators of 12 MOVE! programs located throughout the United States, 5 with high participant retention rates and 7 with low rates. We transcribed and descriptively coded interviews and compared responses from high- and low-retention programs. RESULTS: Characteristics related to retention were provider knowledge of and referral to the program, reputation of the program within the medical facility, the MOVE! meeting schedule, inclusion of physical activity in group meetings, and involvement of the MOVE! physician champion. MOVE! introductory sessions, frequency of group meetings, and meeting topics were not related to retention. Coordinators described efforts to improve retention, including participant contracts and team competitions. Coordinators at 5 high-retention facilities and 1 low-retention facility discussed efforts to improve retention. CONCLUSION: Coordinators identified important program characteristics that could guide improvements to retention in group-based weight-management programs. Training for providers is needed to assist with referral decisions, and program planners should consider incorporating physical activity in group meetings.

Optimizing primary care telephone access and patient satisfaction.

Telephone medicine is often preferred by patients to meet primary care needs and may be associated with high patient satisfaction. This article presents findings about incoming patient calls to primary care for medically based reasons during office hours and reports factors independently associated with telephone encounter satisfaction, considering patient characteristics, call reasons, and staff responsiveness, for a national cohort of primary care users. Interviews were conducted with patients from 18 nationwide primary care clinics during the fall of 2009. Calling for an urgent medical issue was associated with dissatisfaction. Odds of call satisfaction were greater when patients thought staff was friendly (10×), call answer was timely (5×), and needed medical information was provided (7×). These findings can be used for interventions to optimize telephone access and patient satisfaction which is beneficial because satisfactory telephone encounters reduce primary care use and satisfied patients are more likely to be engaged in their health care.

Disaster preparedness and response practices among providers from the Veterans Health Administration and Veterans with spinal cord injuries and/or disorders.

OBJECTIVES: Few empirical studies have examined the disaster preparedness and response practices of individuals with spinal cord injuries and/or disorders (SCI/D) and the healthcare providers who serve them. This study was conducted to understand the experiences of Veterans Health Administration (VHA) providers and Veterans with SCI/D in recent natural disasters, and to identify lessons learned for disaster preparedness and response in the context of SCI/D. DESIGN: Semi-structured interviews were conducted with providers and Veterans recruited through seven VHA facilities that had sustained a disaster since 2003. Audio recordings of the interviews were transcribed; transcripts were analyzed using constant comparative techniques. RESULTS: Forty participants completed an interview, including 21 VHA SCI/D providers and 19 Veterans with SCI/D. Disasters experienced by participants were weather related. While many Veterans were evacuated or admitted to nearby VHA facilities, others chose to stay in their communities. All facilities had formal disaster plans and engaged in related training; however, participants explained that many aspects of a response take shape 'in the moment,' and must address both provider and Veteran needs. Dispersion of resources hindered well-coordinated care, but effective communication, teamwork, advanced warnings, and VHA's electronic medical record facilitated efforts. CONCLUSIONS: Even in the case of thorough planning, Veterans with SCI/D and their healthcare providers are faced with pressing needs during disasters, and identifying strategies to coordinate care is critical. The lessons learned are intended to inform the efforts of healthcare providers who may be involved in the care of individuals with SCI/D in future disasters.

Embracing a health services research perspective on personal health records: lessons learned from the VA My HealtheVet system.

BACKGROUND: Personal health records (PHRs) are designed to help people manage information about their health. Over the past decade, there has been a proliferation of PHRs, but research regarding their effects on clinical, behavioral, and financial outcomes remains limited. The potential for PHRs to facilitate patient-centered care and health system transformation underscores the importance of embracing a broader perspective on PHR research. OBJECTIVE: Drawing from the experiences of VA staff to evaluate the My HealtheVet (MHV) PHR, this article advocates for a health services research perspective on the study of PHR systems. METHODS: We describe an organizing framework and research agenda, and offer insights that have emerged from our ongoing efforts regarding the design of PHR-related studies, the need to address PHR data ownership and consent, and the promotion of effective PHR research collaborations. CONCLUSION: These lessons are applicable to other PHR systems and the conduct of PHR research across different organizational contexts.

Major medical conditions and VA healthcare costs near end of life for veterans with spinal cord injuries and disorders.

We analyzed healthcare costs and medical conditions for 2,008 veterans with spinal cord injuries and disorders (SCI/Ds) near end of life. The average age at SCI/D onset and/ or occurrence was 42 years and at death was 66 years. The conditions that incurred the most costs included cancer (20.9%), influenza and/or pneumonia (15.1%), heart disease (13.5%), septicemia (5.9%), diabetes (5.3%), and stroke (5.1%). The average cost was $24,900 in the second year before end of life and reached $61,900 in the final year. Before end of life, costs accelerated during the final year from $3,100 in month 12 to $14,600 in the final month.

Veterans' access to and use of Medicare and Veterans Affairs health care.

OBJECTIVES: We examined the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services. METHODS: We used a retrospective, cross-sectional design to identify veterans who were eligible to use VA and Medicare health care in calendar year 1999. We analyzed national VA utilization and Medicare claims data. We used descriptive and multivariable generalized ordered logit analyses to examine how patient, geographic, and environmental factors affect the percent reliance on VA and Medicare inpatient and outpatient services. RESULTS: Of the 1.47 million veterans in our study population with outpatient use, 18% were VA-only users, 36% were Medicare-only users, and 46% were both VA and Medicare users. Among veterans with inpatient use, 24% were VA only, 69% were Medicare only, and 6% were both VA and Medicare users. Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care. CONCLUSIONS: VA health care provides an important safety net for vulnerable populations. Targeted approaches that carefully consider the simultaneous impacts of VA and Medicare policy changes on minority and high-risk populations are essential to ensure veterans have access to needed health care.

Disease prevalence and use of preventive services: comparison of female veterans in general and those with spinal cord injuries and disorders.

BACKGROUND: Disease prevalence and use of preventive services may differ between women veterans in general and those with spinal cord injuries and disorders (SCI&D). Prevention is particularly important in SCI&D, and disparities may exist in receipt of this care, particularly when special equipment and body adjustments are needed, among women with SCI&D. METHODS: To compare disease prevalence and preventive service use among female veterans in general and those with SCI&D, we conducted a cross-sectional survey among female veterans in general (n = 478) and those with SCI&D (n = 115). Behavioral Risk Factor Surveillance System (BRFSS) survey questions were administered to veterans with SCI&D and compared with 2003 CDC BRFSS data. RESULTS: Female veterans with SCI&D were similar in age and race but were better educated and less likely to be employed than female veterans in general. Coronary heart disease (CHD) prevalence was higher in those with SCI&D (17% vs. 8%, p < 0.0001). Health status was lower in SCI&D (27%) than in general female veterans (41%), p = 0.002. Fewer women with SCI&D, than female veterans in general reported having received recommended dental care (56% vs. 69%, p = 0.004), colon screening in prior 5 years (59% vs. 72%, p = 0.023) or prior 10 years (67% vs. 92%, p< 0.0001), mammogram (84% vs. 91%, p = 0.019), and Pap smear (88% vs. 98%, p < 0.0001). There were no differences in receipt of respiratory vaccinations or cholesterol screening. CONCLUSIONS: Receipt of services that require the use of equipment, body adjustments, and potential discomfort due to disability was lower in women with SCI&D. Veterans Affairs (VA) is doing well in most areas, but there are gaps in receipt of some preventive services. Efforts to increase preventive care in women with SCI&D should address equipment and access barriers and patient and provider education.

Geographical proximity and health care utilization in veterans with SCI&D in the USA.

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans' likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.