Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10.

BACKGROUND: The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. METHOD: International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. RESULTS: The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. CONCLUSIONS: The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.

Population Smoking Characteristics and Cessation Behaviors in a Nationally Representative Cohort of Hispanic Veterans and Hispanic Non-Veterans.

INTRODUCTION: The proportion of Hispanics in the U.S. Veteran population is expected to increase rapidly in the next several decades. Although Veterans have a heightened smoking risk relative to the civilian population, few studies have examined whether this risk extends to Hispanic Veterans. The aims of the present study were to examine differences in the smoking and cessation characteristics of Hispanic Veterans and Hispanic non-Veterans, and to determine whether these differences persist after controlling for demographics and markers of acculturation. MATERIALS AND METHODS: This was a secondary analysis of the 2014-2015 Tobacco Use Supplement of the Current Population Survey administered by the U.S. Census Bureau. The main analysis included Hispanics aged 18 or older (N = 27,341). Additional analyses were restricted to participants who had smoked at least 100 cigarettes in their lifetime (N = 4,951), and current smokers (N = 2,345). Regressions modeled the associations between Veteran status and demographics, markers of acculturation, smoking characteristics, and cessation behaviors. Additional regressions modeled the associations between Veteran status and the smoking and cessation outcomes while adjusting for demographics and the acculturation variables of U.S. nativity, U.S. citizenship, and English interview language. Probability weights produced nationally representative findings. RESULTS: Hispanic Veterans were older, more likely to be male, and more acculturated than Hispanic non-Veterans. Unadjusted analyses revealed that Hispanic Veterans were more likely to be current daily smokers (8.6% vs. 5.7%, p = 0.015) and much less likely to be never smokers (59.3% vs. 81.0%, p < 0.001) compared to Hispanic non-Veterans. These differences were reduced after adjusting for the demographic and acculturation characteristics of the two groups. However, Hispanic Veterans were still less likely to be never smokers compared to non-Veterans after this adjustment (74.3% vs 80.7%, p < 0.001). In unadjusted analyses, Veterans were less likely to have stopped smoking for one day or longer as part of a quit attempt than non-Veterans (33.2% vs 45.4%, p = 0.056), although this was not a significant difference. Use of telephone quit line was very low for both Hispanic Veterans and Hispanic non-Veterans (4.3%). After adjustment, the difference in the likelihood of stopping smoking for one day or longer as part of a quit attempt was increased, becoming statistically significant (31.4% vs 45.8%, p = 0.030). CONCLUSION: Demographic and acculturation differences account for much, but not all, of the differences in the smoking characteristics and cessation behaviors of Hispanic Veterans and Hispanic non-Veterans. These findings suggest that Hispanic Veterans, and Veterans more broadly, should be a focal point for cessation efforts. These efforts should include facilitating access to under-utilized cessation treatments, and providing coordinated cessation care for Veterans being treated for comorbid health conditions.

Identifying classes of veterans with multiple risk factors.

As researchers examine the efficacy of interventions that simultaneously target more than 1 symptom, it is important to identify ways to help guide research and program development. This study used electronic medical record data to examine the covariation of multiple risk factors regularly assessed among primary care patients. It also examined the health care utilization of those patients identifying where the health care system came in contact with them to help identify the ideal locations these interventions may be most often used. We obtained data for six risk factors, as well as the number of primary care, mental health, and emergency department visits, from Veteran patients with a primary care visit. There were three main groups of primary care patients, identified using latent class analysis and regression. Although the smallest group, the "High Treatment Need" group, had an increased probability of screening positive for all four risk factors, the post-traumatic stress disorder screen was a significant discriminator of this group from the others. Results show that this group had the greatest number of encounters in all health care locations suggesting significant opportunities for intervention. However, future research is needed to examine the current interventions offered and potential avenues where risk factors may be addressed simultaneously.

Are verbal intelligence subtests and reading measures immune to non-credible effort?

The validity of neuropsychological testing is reliant on examinees putting forth adequate effort, yet it has been asserted that verbal subtests from the Wechsler Adult Intelligence Scales (WAIS) are insensitive to suboptimal effort in comparison to other commonly used neuropsychological measures. The current study examined performance differences on the entire WAIS-IV and WRAT-4 Reading, as well as the CVLT-II and several WMS-IV subtests, in 207 Veterans classified into Credible Effort (n = 146) and Non-credible Effort (n = 61) groups. Analyses revealed that the Non-credible Effort group performed significantly lower on all examined measures including verbal tests, with moderate to large effect sizes observed for most tests. Current findings thus indicate that WAIS-IV verbal subtests and reading ability measures, such as on the WRAT-4, are not insensitive to effects of non-credible effort. Consequently it is recommended that these tests not generally be used to estimate baseline intellectual functioning when found in the presence of non-credible effort. While there was broad performance suppression across all measures examined, results also showed a distinct continuum of test susceptibility with some measures being more or less sensitive to inadequate effort. Recommendations for future performance validity test development are presented.

Use of Medicare and DOD data for improving VA race data quality.

We evaluated the improvement in Department of Veterans Affairs (VA) race data completeness that could be achieved by linking VA data with data from Medicare and the Department of Defense (DOD) and examined agreement in values across the data sources. After linking VA with Medicare and DOD records for a 10% sample of VA patients, we calculated the percentage for which race could be identified in those sources. To evaluate race agreement, we calculated sensitivities, specificities, positive predictive values (PPVs), negative predictive values, and kappa statistics. Adding Medicare (and DOD) data improved race data completeness from 48% to 76%. Among older patients (≥65 years), adding Medicare data improved data completeness to nearly 100%. Among younger patients (<65 years), combining Medicare and DOD data improved completeness to 75%, 18 percentage points beyond that achieved with Medicare data alone. PPVs for white and African-American categories were 98.6 and 94.7, respectively, in Medicare and 97.0 and 96.5, respectively, in DOD data using VA self-reported race as the gold standard. PPVs for the non-African-American minority groups were lower, ranging from 30.5 to 48.2. Kappa statistics reflected these patterns. Supplementing VA with Medicare and DOD data improves VA race data completeness substantially. More study is needed to understand poor rates of agreement between VA and external sources in identifying non-African-American minority individuals.

Beyond diagnosis: understanding the healthcare challenges of injured veterans through the application of the International Classification of Functioning, Disability and Health (ICF).

Psychiatric and neurological disorders brought about by exposure to combat can create serious obstacles to community reintegration. Effective therapeutic and rehabilitative methods designed to address disorders that arise from combat are available. Yet there continues to be a need to develop both a deeper understanding of veterans' needs and best-practice methods to alleviate distress and facilitate community participation. Awareness of these needs served as the catalyst for the International Conference on Behavioral Health and Traumatic Brain Injury and is the basis for developing numerous new programs and service refinements across government and non-government organizations. Despite advances, community reintegration remains a complicated endeavor for many veterans returning home who are experiencing traumatic brain- and stress-related disorders. Accurately conceptualizing and codifying symptoms and barriers to community participation, beyond impairment analysis and diagnostic inclusion, is necessary to guide treatment planning and inform programmatic refinements. The International Classification of Function, Disability and Health (ICF) offers a useful taxonomic tool that can assist in refining an understanding of the challenges confronting our returning veterans. In turn, resources can be appropriately allocated, and neuropsychological therapies and other rehabilitation interventions, which assist veterans to resume productive and satisfying lives, will more likely be developed and implemented.

Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals?

CONTEXT: Unplanned readmission within 30 days of discharge is an indicator of hospital quality. PURPOSE: We wanted to determine whether older rural veterans who were enrolled in the VA had different rates of unplanned readmission to VA or non-VA hospitals than their urban counterparts. METHODS: We used the combined VA/Medicare dataset to examine 3,513,912 hospital admissions for older veterans that occurred in VA or non-VA hospitals between 1997 and 2004. We calculated 30-day readmission rates and odds ratios for rural and urban veterans, and we performed a logistic regression analysis to determine whether living in a rural setting or initially using the VA for hospitalization were independent risk factors for unplanned 30-day readmission, after adjusting for age, sex, length of stay of the index admission, and morbidity. FINDINGS: Overall, rural veterans had slightly higher 30-day readmission rates than their urban counterparts (17.96% vs 17.86%; OR 1.006, 95% CI: 1.0004, 1.013). For both rural- and urban-dwelling veterans, readmission after using a VA hospital was more common than after using a non-VA hospital (20.7% vs 16.8% for rural veterans, 21.2% vs 16.1% for urban veterans). After adjusting for other variables, readmission was more likely for rural veterans and following admission to a VA hospital. CONCLUSIONS: Our findings suggest that VA should consider using the unplanned readmission rate as a performance metric, using the non-VA experience of veterans as a performance benchmark, and helping rural veterans select higher performing non-VA hospitals.

A Taxonomy of medical comorbidity for veterans who are homeless.

Homeless veterans have numerous medical and behavioral health problems. Grouping homeless people based on comorbidity patterns may assist in determining severity of illness and triaging health care more effectively. We sought to determine if a finite number of profiles could be identified related to demographic characteristics, living situation, length of homelessness, and referral areas using interview data from 2,733 veterans who were presently or recently homeless. We considered 12 disorders: eye problems, hypertension, cardiovascular problems, COPD/emphysema, tuberculosis, gastrointestinal problems, hepatic disease, neurologic disorders, orthopedic problems, skin problems, and trauma. Ratings were evaluated using cluster analysis. Comparison statistics were used to compare intercluster differences in demographics, homeless situation, and referral recommendations. A four-cluster solution is proposed: generalized illness, hepatic disease, lung disease, and neurologic disorder. Medical health problems are common and heterogeneous in homeless individuals. Classifications of these problems may be useful in planning treatment and predicting outcome.

Recent trends In VA treatment of post-traumatic stress disorder and other mental disorders.

Treating post-traumatic stress disorder (PTSD) among returning Iraq/Afghanistan veterans is a high priority for the U.S. Department of Veterans Affairs (VA). The number of Persian Gulf-era veterans diagnosed with PTSD grew by 8,000 veterans per year from 2003 to 2005. Since 1997, however, the average annual growth in all users of VA specialty mental health services has averaged 37,000 veterans per year, including 22,000 per year with PTSD. This expansion was associated with a 37 percent reduction in mental health visits per veteran per year. The VA has substantially increased funding for PTSD services. Nevertheless, the observed growth in demand requires continued monitoring to assure that the needs of returning veterans are met.

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture.

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.

Veterans and functional status transitions in older Americans.

OBJECTIVES: This research examines the relationship of veteran status with functional status transitions in older Americans. METHODS: Data for this study come from the Survey of Asset and Health Dynamics among the Oldest Old. We use a structural multinomial logit model to decompose the effect of older veterans into the direct effect and the indirect effects via physical health conditions and mental disorders on functional status transitions. RESULTS: Although there is no distinct association among those functionally independent at baseline, veteran status significantly impacts age-dependent transitions from functional dependence to other statuses. At age 85, the excess mortality and the lower level of functional resolution among functionally dependent veterans are considerable. CONCLUSIONS: Physical health is more important than mental health in transmitting the effect of veteran status on functional status transitions in functionally dependent persons.

Modeling an integrative physical examination program for the Departments of Defense and Veterans Affairs.

Current policies governing the Departments of Defense and Veterans Affairs physical examination programs are out of step with current evidence-based medical practice. Replacing periodic and other routine physical examination types with annual preventive health assessments would afford our service members additional health benefit at reduced cost. Additionally, the Departments of Defense and Veterans Affairs repeat the physical examination process at separation and have been unable to reconcile their respective disability evaluation systems to reduce duplication and waste. A clear, coherent, and coordinated strategy to improve the relevance and utility of our physical examination programs is long overdue. This article discusses existing physical examination programs and proposes a model for a new integrative physical examination program based on need, science, and common sense.

What was different about exposures reported by male Australian Gulf War veterans for the 1991 Persian Gulf War, compared with exposures reported for other deployments?

This study identified chemical and environmental exposures specifically associated with the 1991 Persian Gulf War. Exposures were self-reported in a postal questionnaire, in the period of 2000-2002, by 1,424 Australian male Persian Gulf War veterans in relation to their 1991 Persian Gulf War deployment and by 625 Persian Gulf War veterans and 514 members of a military comparison group in relation to other active deployments. Six of 28 investigated exposures were experienced more frequently during the Persian Gulf War than during other deployments; these were exposure to smoke (odds ratio [OR], 4.4; 95% confidence interval, 3.0-6.6), exposure to dust (OR, 3.7; 95% confidence interval, 2.6-5.3), exposure to chemical warfare agents (OR, 3.9; 95% confidence interval, 2.1-7.9), use of respiratory protective equipment (OR, 13.6; 95% confidence interval, 7.6-26.8), use of nuclear, chemical, and biological protective suits (OR, 8.9; 95% confidence interval, 5.4-15.4), and entering/inspecting enemy equipment (OR, 3.1; 95% confidence interval, 2.1-4.8). Other chemical and environmental exposures were not specific to the Persian Gulf War deployment but were also reported in relation to other deployments. The number of exposures reported was related to service type and number of deployments but not to age or rank.

Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans.

BACKGROUND: Following the 1991 Gulf War, some veterans expressed concerns regarding their reproductive health. Our objective was to assess whether an association exists between deployment to the 1991 Gulf War and self-reported adverse pregnancy outcomes. METHODS: Using a modified Dillman technique with telephone follow-up, we conducted a survey via a postal questionnaire from February 1996-August 1997 to compare selected reproductive outcomes among 10,000 US veterans deployed to the 1991 Gulf War with those of 10,000 nondeployed Gulf War era veterans. RESULTS: A total of 8742 individuals responded to the survey, a response rate of 51 percent. Using multivariable analyses, results showed no differences in number of reported pregnancies between Gulf War veterans and nondeployed veterans. Among 2233 female and 2159 male participants, there were no differences in birth weight of infants born to Gulf War veterans compared with nondeployed Gulf War era veterans. In multivariable models, male and female Gulf War veterans did not significantly differ in risk for ectopic pregnancies, stillbirths, or miscarriages when compared with nondeployed veterans of the same era. CONCLUSIONS: These results do not suggest an association between service in the 1991 Gulf War and adverse reproductive outcomes for both male and female veterans during the 4 years after the war.

Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service.

We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.

Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study.

BACKGROUND: Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes. METHODS: We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control. RESULTS: The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c > or = 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control. CONCLUSION: In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.

Differences in cause of death of Washington State veterans who did and did not use Department of Veterans Affairs healthcare services.

Relatively little is known about the cause of death in the veteran population, although more is known about the cause of death in Vietnam veterans or veterans receiving mental health services. This article compares characteristics and causes of death in Washington State veterans who did and did not use Department of Veterans Affairs (VA) healthcare services in the 5 years prior to death. This study included 62,080 veterans who died between 1998 and 2002, of whom 21% were users of VA healthcare services. The veterans who used VA healthcare services were younger, more often men, less educated, more often divorced, and more often smokers than the veterans who did not use VA healthcare services. Both female and male veterans who used VA healthcare services were more likely to die from drug- and/or alcohol-related causes. These findings suggest that the VA patient population is socially disadvantaged and more severely affected by substance-use disorders compared with veterans who do not use VA healthcare services.

Exploring veteran identity and health services use among Native American veterans.

The objectives of this study were to describe the military experiences of Native American veterans and to explore how factors related to veteran identity influence their use of health services. Study participants completed a demographic and health questionnaire, followed by participation in a focus group session. The findings revealed that, despite their negative experiences during military service, most participants had a positive veteran identity. Almost 46% of participants reported having a service-related illness or injury. Almost one-third (28.2%) used the Indian Health Service (IHS) exclusively for their health care, followed by those who used both IHS and Veterans Affairs (VA) services (23.5%), followed by VA-only users (21.2%). We conclude that Native American veterans highly identify with their military service but may turn to IHS for their medical care. The data support the current VA policy of strengthening coordination with the IHS to ensure that the medical needs of Native American veterans are addressed.

Incarceration and veterans of the first Gulf War.

OBJECTIVE: This study investigated the prevalence of incarceration and the association with deployment among veterans of the first Persian Gulf War (GW). METHODS: A structured telephone interview of military personnel from Iowa deployed to the Persian Gulf and a comparison sample of nondeployed military personnel was conducted. The interview consisted of validated questions, validated instruments, and investigator-derived questions to assess relevant medical and psychiatric conditions. A total of 4,886 subjects were randomly drawn from one of four study domains, i.e., GW regular military, GW National Guard/Reserve, non-GW regular military, or non-GW National Guard/Reserve. Symptoms of medical conditions, psychiatric disorders, and health care utilization were the main outcome measures. RESULTS: Nearly one-quarter (845 of 3,695 subjects, 22.9%) had been incarcerated at some point before the interview ("ever incarcerated"). Ever incarcerated veterans had a higher frequency of psychiatric and medical comorbidity and higher rates of health care utilization. Ever incarcerated status was associated with male gender, enlisted rank, lower educational levels, low levels of military preparedness, discharge from service, cigarette smoking, antisocial traits, court martial and/or other military discipline, having seen a mental health professional, and having used illegal drugs. GW veterans who participated in combat had a modestly higher risk for incarceration after the GW than did noncombatants (odds ratio, 1.6; 95% confidence interval, 1.0-2.5). CONCLUSIONS: Military recruits with a history of incarceration more often displayed problematic behaviors, more often developed psychiatric/medical conditions, and had high rates of health care utilization. A history of incarceration may be a behavioral marker for substance abuse, antisocial behavior, and mental illness. Importantly, GW deployment carried no increased risk of subsequent incarceration overall.