Application of a comprehensive disability measure: Disability prevalence among US Veterans and non-veterans from the National Health Interview Survey Data from 2015 to 2018.

BACKGROUND: Current measures of condition-specific disabilities or those capturing only severe limitations may underestimate disability prevalence, including among Veterans. OBJECTIVES: To develop a comprehensive measure to characterize and compare disabilities among US Veterans and non-Veterans. METHODS: Using 2015-2018 pooled cross-sectional National Health Interview Survey data, we compared the frequency and survey-weighted prevalence of non-mutually exclusive sensory, social, and physical disabilities by Veteran status. We developed a measure for and examined the frequency and survey-weighted prevalence of eight mutually exclusive disability categories-sensory only; physical only; social only; sensory and physical; social and sensory; physical and social; and sensory, social, and physical. RESULTS: Among 118,818 NHIS respondents, 11,943 were Veterans. Veterans had a greater prevalence than non-Veterans of non-mutually exclusive physical [52.01% vs. 34.68% (p < 0.001)], sensory [44.47% vs. 21.79% (p < 0.001)], and social [17.20% vs. 11.61% (p < 0.001)] disabilities (after survey-weighting). The most frequently reported mutually exclusive disability categories for both Veterans and non-Veterans were sensory and physical (19.20% and 8.02%, p < 0.001) and physical only (16.24% and 15.69%, p = 0.216) (after survey-weighting). The least frequently reported mutually exclusive disability categories for both Veterans and non-Veterans were social only (0.31% and 0.44%, p = 0.136) and sensory and social (0.32% and 0.20%, respectively, 0.026) (after survey-weighting). CONCLUSIONS: Our disability metric demonstrates that Veterans have a higher disability prevalence than non-Veterans, and a higher prevalence than previously reported. Public policy and future research should consider this broader definition of disability to more fully account for the variable needs of people with disabilities.

AGE-RELATED MACULAR DEGENERATION INJECTION FREQUENCY: Effects of Distance Traveled and Travel Support.

PURPOSE: Although efficacious, intravitreal anti-vascular endothelial growth factor therapy regimens for neovascular age-related macular degeneration can prove difficult for patients to adhere to because of high cost and burden of transportation. METHODS: Analysis of electronic health record data from the San Francisco Veterans Administration Medical Center eye clinic (January 1, 2010 to December 31, 2019) was performed, extracting demographic data, anti-vascular endothelial growth factor injection history, and enrollment in the SFVA travel benefit program. Two-tailed P -values were calculated for Poisson regression examining average number of injections per year as the outcome and distance traveled as the primary predictor. Travel benefit was evaluated as a modifying effect on the distance-injection relationship. RESULTS: Three hundred and eighteen patients who received intravitreal injection for treatment of neovascular age-related macular degeneration were included in the analysis. Median (interquartile range) distance to clinic was 31.5 miles (7.4-69.4 miles). Driving distance in miles was inversely associated with average number of injections per year. Among all 318 patients, for every additional 100 miles a patient lived from our clinic, the patient received on average 2.5 fewer injections per year ( distance = -0.0025, P < 0.001), but this was not the case for patients with travel benefits ( distance = -0.0011, P = 0.362). CONCLUSION: The greater the distance from a patient's eye clinic, the lower the average number of injections per year. However, travel benefits mitigated this relationship, highlighting opportunities for improving patient's adherence through assistance programs.

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy.

BACKGROUND: Given efforts to taper patients off long-term opioid therapy (LTOT) because of known harms, it is important to understand if patients and providers align in LTOT treatment goals. OBJECTIVE: To investigate patient and provider perceptions about the harms and benefits of continuing and discontinuing LTOT. DESIGN: Qualitative study PARTICIPANTS: Patients and providers with experiences with LTOT for pain in two Veterans Health Affairs regions. APPROACH: We conducted semi-structured interviews and analyzed data using rapid qualitative analysis to describe patient and provider preferences about LTOT continuation and discontinuation and non-opioid pain treatments. KEY RESULTS: Participants (n=43) included 28/67 patients and 15/17 providers. When discussing continuing LTOT, patients emphasized the benefits outweighed the harms, whereas providers emphasized the harms. Participants agreed on the benefits of continuing LTOT for improved physical functioning. Provider-reported benefits of continuing LTOT included maintaining the status quo for patients without opioid alternatives or who were at risk for illicit drug use. Participants were aligned regarding the harms of negative side-effects (e.g., constipation) from continued LTOT. In contrast, when discussing LTOT tapering and discontinuation, providers underscored how benefits outweighed the harms, citing patients' improved well-being and pain management with tapering or alternatives. Patients did not foresee benefits to potential LTOT tapers or discontinuation and were worried about pain management in the absence of LTOT. When discussing non-opioid pain treatments, participants emphasized that they were adjunctive to opioid therapy rather than a replacement (except for cannabis). Providers described the importance of mental health services to manage pain, which differed from patients who focused on treatments to improve strength and mobility and reduce pain. CONCLUSIONS: Patients emphasized the benefits of continuing LTOT for pain management and well-being, which differed from providers' emphasis on the benefits of discontinuing LTOT. Patient and provider differences are important for informing patient-centered care and decisions around continuing, tapering, or discontinuing LTOT.

Trends in substance use disorder diagnoses among Veterans, 2009-2019.

BACKGROUND AND OBJECTIVES: Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data. METHODS: We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD. RESULTS: Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances. DISCUSSION AND CONCLUSIONS: Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults. SCIENTIFIC SIGNIFICANCE: These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.

The Heart and Cannabis (THC) Cohort: Differences in Baseline Health and Behaviors by Cannabis Use.

BACKGROUND: Evidence on the cardiovascular health effects of cannabis use is limited. We designed a prospective cohort study of older Veterans (66 to 68 years) with coronary artery disease (CAD) to understand the cardiovascular consequences of cannabis use. We describe the cohort construction, baseline characteristics, and health behaviors that were associated with smoking cannabis. OBJECTIVE: To understand the cardiovascular consequences of cannabis use. DESIGN: We designed a prospective cohort study of older Veterans (66 to 68 years) with CAD. PARTICIPANTS: A total of 1,015 current cannabis smokers and 3,270 non-cannabis smokers with CAD. MAIN MEASURES: Using logistic regression, we examined the association of baseline variables with smoking cannabis in the past 30 days. RESULTS: The current cannabis smokers and non-current smokers were predominantly male (97.2% vs 97.1%, p=0.96). Characteristics associated with recent cannabis use in multivariable analyses included lack of a high school education (odds ratio [OR] 2.15, 95% confidence interval [CI]: 1.10 to 4.19), financial difficulty (OR 1.47, 95% CI: 1.02 to 2.11), tobacco use (OR 3.02, 95% CI: 1.66 to 5.48), current drug use (OR 2.82, 95% CI: 1.06 to 7.46), and prior drug use (OR 2.84, 95% CI: 2.11 to 3.82). In contrast, compared to individuals with 0 to 1 comorbid conditions, those with 5 chronic conditions or more (OR 0.43, 95% CI: 0.27 to 0.70) were less likely to smoke cannabis. CONCLUSIONS: In this older high-risk cohort, smoking cannabis was associated with higher social and behavioral risk, but with fewer chronic health conditions.

Provider perceptions of challenges to identifying women Veterans with hazardous substance use.

BACKGROUND: Approximately one-third of women Veterans Health Administration (VHA) users have substance use disorders (SUD). Early identification of hazardous substance use in this population is critical for the prevention and treatment of SUD. We aimed to understand challenges to identifying women Veterans with hazardous substance use to improve future referral, evaluation, and treatment efforts. METHODS: Design: We conducted a secondary analysis of semi-structured interviews conducted with VHA interdisciplinary women's SUD providers at VA Greater Los Angeles Healthcare System. PARTICIPANTS: Using purposive and snowball sampling we interviewed 17 VHA providers from psychology, social work, women's health, primary care, and psychiatry. APPROACH: Our analytic approach was content analysis of provider perceptions of identifying hazardous substance use in women Veterans. RESULTS: Providers noted limitations across an array of existing identification methodologies employed to identify women with hazardous substance use and believed these limitations were abated through trusting provider-patient communication. Providers emphasized the need to have a process in place to respond to hazardous use when identified. Provider level factors, including provider bias, and patient level factors such as how they self-identify, may impact identification of women Veterans with hazardous substance use. Tailoring language to be sensitive to patient identity may help with identification in women Veterans with hazardous substance use or SUD who are not getting care in VHA but are eligible as well as those who are not eligible for care in VHA. CONCLUSIONS: To overcome limitations of existing screening tools and processes of identifying and referring women Veterans with hazardous substance use to appropriate care, future efforts should focus on minimizing provider bias, building trust in patient-provider relationships, and accommodating patient identities.

Incidence of Severe COVID-19 Illness Following Vaccination and Booster With BNT162b2, mRNA-1273, and Ad26.COV2.S Vaccines.

Importance: Evidence describing the incidence of severe COVID-19 illness following vaccination and booster with BNT162b2, mRNA-1273, and Ad26.COV2.S vaccines is needed, particularly for high-risk populations. Objective: To describe the incidence of severe COVID-19 illness among a cohort that received vaccination plus a booster vaccine dose. Design, Setting, and Participants: Retrospective cohort study of adults receiving care at Veterans Health Administration facilities across the US who received a vaccination series plus 1 booster against SARS-CoV-2, conducted from July 1, 2021, to May 30, 2022. Patients were eligible if they had received a primary care visit in the prior 2 years and had documented receipt of all US Food and Drug Administration-authorized doses of the initial mRNA vaccine or viral vector vaccination series after December 11, 2020, and a subsequent documented booster dose between July 1, 2021, and April 29, 2022. The analytic cohort consisted of 1 610 719 participants. Exposures: Receipt of any combination of mRNA-1273 (Moderna), BNT162b2 (Pfizer-BioNTech), and Ad26.COV2.S (Janssen/Johnson & Johnson) primary vaccination series and a booster dose. Main Outcomes and Measures: Outcomes were breakthrough COVID-19 (symptomatic infection), hospitalization with COVID-19 pneumonia and/or death, and hospitalization with severe COVID-19 pneumonia and/or death. A subgroup analysis of nonoverlapping populations included those aged 65 years or older, those with high-risk comorbid conditions, and those with immunocompromising conditions. Results: Of 1 610 719 participants, 1 100 280 (68.4%) were aged 65 years or older and 132 243 (8.2%) were female; 1 133 785 (70.4%) had high-risk comorbid conditions, 155 995 (9.6%) had immunocompromising conditions, and 1 467 879 (91.1%) received the same type of mRNA vaccine (initial series and booster). Over 24 weeks, 125.0 (95% CI, 123.3-126.8) per 10 000 persons had breakthrough COVID-19, 8.9 (95% CI, 8.5-9.4) per 10 000 persons were hospitalized with COVID-19 pneumonia or died, and 3.4 (95% CI, 3.1-3.7) per 10 000 persons were hospitalized with severe pneumonia or died. For high-risk populations, incidence of hospitalization with COVID-19 pneumonia or death was as follows: aged 65 years or older, 1.9 (95% CI, 1.4-2.6) per 10 000 persons; high-risk comorbid conditions, 6.7 (95% CI, 6.2-7.2) per 10 000 persons; and immunocompromising conditions, 39.6 (95% CI, 36.6-42.9) per 10 000 persons. Subgroup analyses of patients hospitalized with COVID-19 pneumonia or death by time after booster demonstrated similar incidence estimates among those aged 65 years or older and with high-risk comorbid conditions but not among those with immunocompromising conditions. Conclusions and Relevance: In a US cohort of patients receiving care at Veterans Health Administration facilities during a period of Delta and Omicron variant predominance, there was a low incidence of hospitalization with COVID-19 pneumonia or death following vaccination and booster with any of BNT162b2, mRNA-1273, or Ad26.COV2.S vaccines.

Complementary and Integrated Health Approaches: What Do Veterans Use and Want.

OBJECTIVES: Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches. METHODS: Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017. RESULTS: In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA. CONCLUSIONS: Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.

Rates and Impact of Adherence to Recommended Care for Unhealthy Alcohol Use.

BACKGROUND: Unhealthy alcohol use is a major worldwide health problem. Yet few studies have assessed provider adherence to the alcohol-related care recommended in clinical practice guidelines, nor links between adherence to recommended care and outcomes. OBJECTIVES: To describe quality of care for unhealthy alcohol use and its impacts on drinking behavior RESEARCH DESIGN: Prospective observational cohort study of quality of alcohol care for the population of patients screening positive for unhealthy alcohol use in a large Veterans Affairs health system. PARTICIPANTS: A total of 719 patients who screened positive for unhealthy alcohol use at one of 11 primary care practices and who completed baseline and 6-month telephone interviews. MAIN MEASURES: Using administrative encounter and medical record data, we assessed three composite and 21 individual process-based measures of care delivered across primary and specialty care settings. We assessed self-reported daily alcohol use using telephone interviews at baseline and 6-month follow-up. KEY RESULTS: The median proportion of patients who received recommended care across measures was 32.8% (range < 1% for initiating pharmacotherapy to 93% for depression screening). There was negligible change in drinking for the study population between baseline and 6 months. In covariate-adjusted analyses, no composites were significantly associated with changes in heavy drinking days or drinks per week, and just one of nine individual measures tested was significantly associated. In a subsample of patients drinking above recommended weekly limits prior to screening, two of nine individual measures were significantly associated. CONCLUSIONS: This study shows wide variability in receipt of recommended care for unhealthy alcohol use. Receipt of recommended interventions for reducing drinking was frequently not associated with decreased drinking. Results suggest deficits in provision of comprehensive alcohol care and in understanding how to improve population-based drinking outcomes.

Identifying women veterans with unhealthy alcohol use using gender-tailored screening.

BACKGROUND AND OBJECTIVES: To assess the impact of gender-tailored alcohol screening criteria. METHODS: Among N = 1,349 women, we calculated the proportion screening positive for unhealthy alcohol use with non-tailored versus gender-tailored criteria (a gender-tailored binge-drinking item, lower screen-positive threshold, or both). RESULTS: Three percent more women screened positive with a modified binge-drinking question, most reporting risky drinking. Fifteen percent more women screened positive with a lower threshold; most did not report risky drinking. DISCUSSION AND CONCLUSIONS: Gender-tailored binge-drinking questions may improve detection of women's unhealthy alcohol use. SCIENTIFIC SIGNIFICANCE: These results can inform future efforts to improve alcohol screening for women. (Am J Addict 2018;27:97-100).

Differences by Veteran/civilian status and gender in associations between childhood adversity and alcohol and drug use disorders.

PURPOSE: To examine differences by US military Veteran status and gender in associations between childhood adversity and DSM-5 lifetime alcohol and drug use disorders (AUD/DUD). METHODS: We analyzed nationally representative data from 3119 Veterans (n = 379 women; n = 2740 men) and 33,182 civilians (n = 20,066 women; n = 13,116 men) as provided by the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). We used weighted multinomial logistic regression, tested interaction terms, and calculated predicted probabilities by Veteran status and gender, controlling for covariates. To test which specific moderation contrasts were statistically significant, we conducted pairwise comparisons. RESULTS: Among civilians, women had lower AUD and DUD prevalence than men; however, with more childhood adversity, this gender gap narrowed for AUD and widened for DUD. Among Veterans, in contrast, similar proportions of women and men had AUD and DUD; with more childhood adversity, AUD-predicted probability among men surpassed that of women. Childhood adversity elevated AUD probability among civilian women to levels exhibited by Veteran women. Among men, Veterans with more childhood adversity were more likely than civilians to have AUD, and less likely to have DUD. CONCLUSIONS: Childhood adversity alters the gender gap in AUD and DUD risk, and in ways that are different for Veterans compared with civilians. Department of Defense, Veterans Affairs, and community health centers can prevent and ameliorate the harmful effects of childhood adversity by adapting existing behavioral health efforts to be trauma informed, Veteran sensitive, and gender tailored.

Does Documented Brief Intervention Predict Decreases in Alcohol Use in Primary Care?

BACKGROUND: Brief intervention (BI) is recommended for patients with unhealthy alcohol use, but the effectiveness of BI in usual care settings remains unclear. OBJECTIVE: We evaluated whether BI predicts decreases in drinking 6 months after a positive screen for unhealthy alcohol use. METHOD: We enrolled patients who recently screened positive for unhealthy alcohol use during a routine screen in Veterans Health Administration primary care. We conducted medical record review to assess whether providers documented advice to reduce or abstain, feedback about risks to health, feedback about how patient drinking compares to norms or recommended limits, and discussion of drinking-related goals. BI elements were coded from 7 days before the date of the positive screen to 60 days after. We conducted baseline and 6-month follow-up telephone interviews to assess change in past 30-day drinking. We fit regression models examining each BI element and another model for the total count of instances of any combination of elements. RESULTS: Of the 327 patients included, 86% had at least one documented instance of receiving advice, 86% had risk feedback, 55% had normative feedback, 38% had goal discussion, and 75% had three or more instances of any combination of elements of BI. None of the individual BI elements, nor the total number of instances, were significantly associated with decreased drinking. CONCLUSIONS: Results suggest that provider documentation of elements of BI and increasing numbers of instances of BI elements were not associated with decreased heavy drinking at 6-month follow-up among patients identified with unhealthy alcohol use.

The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans.

BACKGROUND: Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. OBJECTIVES: To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. DESIGN: Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. PARTICIPANTS: Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). MAIN MEASURES: We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. KEY RESULTS: Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). CONCLUSIONS: Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Prevalence of substance misuse among US veterans in the general population.

BACKGROUND AND OBJECTIVES: Epidemiologic data on substance misuse prevalence among US Veterans are crucial to plan for Veterans' future healthcare needs. We estimated US Veterans' age-specific, overall, and age-adjusted prevalence of substance misuse, assessed whether prevalence differed between Veterans and civilians, and examined temporal trends in prevalence. METHODS: Substance-related measures were obtained from the National Surveys on Drug Use and Health, 2002-2012 (N = 24,210 Veterans; 338,556 civilians). RESULTS: Among women and men Veterans overall, past-month heavy episodic drinking and daily cigarette smoking were the most prevalent types of substance misuse. For Veteran women and men ages 18-25, the prevalence of past-year illicit drug use was 29% and 38%, which was comparable to the prevalence of past-month daily cigarette smoking, and the prevalence of past-year prescription drug misuse was 14% and 18%. For men ages 18-25, heavy episodic drinking, daily cigarette smoking, alcohol use disorder (AUD), and substance use disorder were more prevalent among Veterans than civilians. For women, the age-specific, overall, and age-adjusted prevalence of daily cigarette smoking was generally greater among Veterans than civilians. There was a decreasing temporal trend in overall AUD prevalence among Veteran men, reflecting a decreasing trend in age-specific prevalence among Veteran men ages 35-49. DISCUSSION AND CONCLUSIONS: Young Veterans' high prevalence of substance misuse, and the generally high prevalence of daily smoking among Veterans, underscore the need for evidence-based assessments and treatment options that are accessible and effective for Veterans. SCIENTIFIC SIGNIFICANCE: This study provides foundational information on the epidemiology of substance misuse among Veterans. (Am J Addict 2017;26:357-365).

Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"?

BACKGROUND: Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators. OBJECTIVE: In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion. DESIGN: Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes. PARTICIPANTS: All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. MAIN MEASURES: The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact. KEY RESULTS: Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001). CONCLUSIONS: These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.

Alcohol and drug misuse, abuse, and dependence in women veterans.

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

Travel time and attrition from VHA care among women veterans: how far is too far?

BACKGROUND: Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care. OBJECTIVE: We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients. RESEARCH DESIGN: This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients. SUBJECTS: In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009. MEASURES: An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates. RESULTS: Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality. CONCLUSIONS: Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.