Self-Reported Social Determinants of Health and Area-Level Social Vulnerability.

Importance: Many health care systems are investing resources in identifying social determinants of health (SDoH) needs and facilitating interventions among the populations they serve. Because self-reported SDoH information is lacking, area-level measures are often used to estimate needs and direct resources. Objective: To describe the large-scale deployment of SDoH assessments by a health system and determine the extent to which self-reported SDoH needs identified therein are associated with census tract-level social vulnerability measured using the Social Vulnerability Index (SVI). Design, Setting, and Participants: This cross-sectional study assessed SDoH needs between January 1, 2020, and April 30, 2023, in both payer and clinical care settings. Modalities included telephonic outreach, face-to-face clinical interactions, self-entry into a tablet or kiosk, and web-based survey tools. Participants included individuals who responded to the assessment and had sufficient information for census tract identification. Respondents included both Highmark Health Plan members and nonmembers. Health plan members responded to the assessment through health plan programs or platforms, and both members and nonmembers responded to assessments during inpatient or outpatient encounters with the affiliated health system. Main Outcomes and Measures: Overall and domain-specific SDoH needs self-reported through assessments, and severity and complexity of needs identified. Residential social vulnerability measures included overall SVI and the 4 conceptual themes comprising overall SVI. Results: In total, 841 874 assessments were recorded for 401 697 individuals (55.1% women; median [IQR] age, 55 [41-70] years). Social determinants of health needs were identified in 120 769 assessments (14.3%). Across all SDoH domains, increasing SVI was associated with a higher positivity rate (eg, 11.2% of those residing in the lowest-risk SVI quintile reported a need compared with 22.7% among those residing in the highest-risk quintile). Associations varied by SDoH domain and SVI theme. After adjusting for demographic and screening characteristics, odds of positive screening among those residing in the highest-risk SVI quintile were 1.74 (95% CI, 1.62-1.86) to 3.73 (95% CI, 3.48-4.00) times the odds among those residing in lowest risk quintile. Conclusions and Relevance: In this cross-sectional study, the overall level of SDoH needs generally corresponded to area-level vulnerability. Some SDoH domains appeared far more sensitive to community characteristics than others. Notably, even among individuals from the highest-risk areas, the positive screening rate was roughly 1 in 4. These findings underscore the importance of individual-level SDoH data for service provision planning and health services research.

Association between diseases of despair and atherosclerotic cardiovascular disease among insured adults in the USA: a retrospective cohort study from 2017 to 2021.

OBJECTIVES: To assess associations between diseases of despair (DoD) and incident atherosclerotic cardiovascular disease (ASCVD) among insured adults in the USA. DESIGN: Retrospective cohort study. SETTING: Highmark insurance claims data in the USA from 2017 to 2021. PARTICIPANTS: Adults with at least 10 months of continuous insurance enrolment, no record of ASCVD in the 2016 baseline year and no missing data on study variables. PRIMARY AND SECONDARY OUTCOME MEASURES: Cox proportional hazard regression was used to calculate crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess risk of ASCVD (composite of ischaemic cardiomyopathy, non-fatal ischaemic stroke, peripheral arterial disease or non-fatal acute myocardial infarction) by baseline DoD overall, and by the component conditions comprising DoD (alcohol-related disorders, substance-related disorders, suicidality) individually and in combination. RESULTS: The DoD-exposed group had an age-adjusted rate of 20.5 ASCVD events per 1000 person-years, compared with 11.7 among the unexposed. In adjusted models, overall DoD was associated with increased risk of incident ASCVD (HR 1.42, 95% CI 1.36 to 1.47). Individually and in combination, component conditions of DoD were associated with higher risk for ASCVD relative to no DoD. Substance-related disorders were associated with 50% higher risk of incident ASCVD (HR 1.5, 95% CI 1.41 to 1.59), alcohol-related disorders and suicidality/intentional self-harm were associated with 33% and 30% higher risk, respectively (HR 1.33, 95% CI 1.26 to 1.41; HR 1.30, 95% CI 1.11 to 1.52). Co-occurring DoD components conferred higher risk still. The highest risk combination was substance-related disorders+suicidality (HR 2.01, 95% CI 1.44 to 2.82). CONCLUSIONS: Among this cohort of insured adults, documented DoD was associated with increased ASCVD risk. Further research to understand and address cardiovascular disease prevention in those with DoD could reduce costs, morbidity and mortality. Further examination of overlapping structural factors that may be contributing to concurrent rises in ASCVD and DoD in the USA is needed.

Emergency health services use and medically-treated suicidal behaviors following depression screening among adolescents: A longitudinal cohort study.

The primary goal of depression screening is to reduce adverse psychiatric outcomes, which may have downstream implications for reducing avoidable health services use. The objective of this study was to examine the association of depression screening with emergency health services use and medically-treated suicidal behaviors among adolescents in the U.S. This longitudinal cohort study used insurance claims data from 57,732 adolescents who had at least one well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression to similar adolescents who were not screened for depression during the well-visit. Outcomes were examined over two-year follow-up and included emergency department use and inpatient hospitalizations for depression-related reasons, mental health-related reasons, and any reason as well as medically-treated suicidal behaviors. Log-binomial regression models were used to examine associations between depression screening and each outcome in the matched sample. Heterogeneity of associations by sex was examined with interaction terms. Being screened for depression was not consistently associated with emergency department use (depression-related reasons: RR = 1.00, 95% CI = 0.76-1.30; mental health-related reasons: RR = 1.02, 95% CI = 0.80-1.29; any reason: RR = 0.96, 95% CI = 0.83-1.11), inpatient hospitalizations (depression-related reasons: RR = 1.05, 95% CI = 0.84-1.31; mental health-related reasons: RR = 1.16, 95% CI = 1.00-1.33; any reason: RR = 1.05, 95% CI = 0.99-1.12), or medically-treated suicidal behaviors (RR = 0.83, 95% CI = 0.51-1.36). Associations were similar in magnitude among male and female adolescents. The results of this study suggest that depression screening, as it is currently practiced in the U.S., may not deter avoidable health services use among adolescents.

Diagnoses and Treatment After Depression Screening in Primary Care Among Youth.

INTRODUCTION: Depression screening is universally recommended for adolescents presenting in primary care settings in the U.S. However, little is known about how depression screening affects the likelihood of being diagnosed with a mental disorder or accessing mental health care over time. METHODS: This longitudinal cohort study used insurance claims data from adolescents who attended a well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression with similar unscreened adolescents. Diagnoses and treatment uptake were examined over a 6-month follow-up and included depression diagnoses, mood-related diagnoses, antidepressant medications, any mental health medication, and psychotherapy. Heterogeneity of associations by sex was also examined. Analyses were conducted from December 2020 to June 2021. RESULTS: The sample included 57,732 adolescents (mean age, 14.26 years; 48.9% female). Compared with adolescents who were not screened for depression, adolescents screened for depression were 30% more likely to be diagnosed with depression (risk ratio=1.30, 95% CI=1.11, 1.52) and 17% more likely to receive a mood-related diagnosis (risk ratio=1.17, 95% CI=1.08, 1.27) but were not more likely to be treated with an antidepressant medication (risk ratio=1.11, 95% CI=0.82, 1.51), any mental health medication (risk ratio=1.15, 95% CI=0.87, 1.53), or psychotherapy (risk ratio=1.13, 95% CI=0.98, 1.31). Associations were generally stronger among female adolescents. CONCLUSIONS: Adolescents who were screened for depression during a well-visit were more likely to receive a diagnosis of depression or a mood-related disorder in the 6 months after screening. Future research should explore methods for increasing treatment uptake after screening.

Perceptions of Diseases of Despair by Members of Rural and Urban High-Prevalence Communities: A Qualitative Study.

Importance: Diseases of despair (ie, mortality or morbidity from suicidality, drug abuse, and alcoholism) were first characterized as increasing in rural White working-class populations in midlife with low educational attainment and associated with long-term economic decline. Excess mortality now appears to be associated with working-class citizens across demographic and geographic boundaries, but no known qualitative studies have engaged residents of rural and urban locales with high prevalence of diseases of despair to learn their perspectives. Objective: To explore perceptions about despair-related illness and potential intervention strategies among diverse community members residing in discrete rural and urban hotspots. Design, Setting, and Participants: In this qualitative study, high-prevalence hotspots for diseases of despair were identified from health insurance claims data in Central Pennsylvania. Four focus groups were conducted with 60 community members in organizations and coalitions from 3 census block group hotspot clusters in the health system between September 2019 and January 2020. Focus groups explored awareness and beliefs about causation and potential intervention strategies. Main Outcomes and Measures: A descriptive phenomenological approach was applied to thematic analysis, and a preliminary conceptual model was constructed to describe how various factors may be associated with perpetuating despair and with public health. Results: In total, 60 adult community members participated in 4 focus groups (44 women, 16 men; 40 White non-Hispanic, 17 Black, and 3 Hispanic/Latino members). Three focus groups with 43 members were held in rural areas with high prevalence of diseases of despair, and 1 focus group with 17 members in a high-prevalence urban area. Four themes emerged with respect to awareness and believed causation of despair-related illness, and participants identified common associated factors, including financial distress, lack of critical infrastructure and social services, deteriorating sense of community, and family fragmentation. Intervention strategies focused around 2 themes: (1) building resilience to despair through better community and organizational coordination and peer support at the local level and (2) encouraging broader state investments in social services and infrastructure to mitigate despair-related illness. Conclusions and Relevance: In this qualitative study, rural and urban community members identified common factors associated with diseases of despair, highlighting the association between long-term political and economic decline and public health and a need for both community- and state-level solutions to address despair. Health care systems participating in addressing community health needs may improve processes to screen for despair (eg, social history taking) and codesign primary, secondary, and tertiary interventions aimed at addressing factors associated with distress. Such actions have taken on greater urgency with the COVID-19 pandemic.

Trends in the diagnosis of diseases of despair in the United States, 2009-2018: a retrospective cohort study.

BACKGROUND AND OBJECTIVE: Increasing mortality and decreasing life expectancy in the USA are largely attributable to accidental overdose, alcohol-related disease and suicide. These 'deaths of despair' often follow years of morbidity, yet little is known about trends in the clinical recognition of 'diseases of despair'. The objective of this study is to characterise rates of clinically documented diseases of despair over the last decade and identify sociodemographic risk factors. DESIGN: Retrospective study using a healthcare claims database with 10 years of follow-up. SETTING: Participants resided nationwide but were concentrated in US states disproportionately affected by deaths of despair, including Pennsylvania, West Virginia and Delaware. PARTICIPANTS: Cohort included 12 144 252 participants, with no restriction by age or gender. OUTCOME MEASURES: Diseases of despair were defined as diagnoses related to alcohol misuse, substance misuse and suicide ideation/behaviours. A lookback period was used to identify incident diagnoses. Annual and all-time incidence/prevalence estimates were computed, along with risk for current diagnosis and patterns of comorbidity. RESULTS: 515 830 participants received a disease of despair diagnosis (58.5% male, median 36 years). From 2009 to 2018, the prevalence of alcohol-related, substance-related and suicide-related diagnoses respectively increased by 37%, 94%, and 170%. Ages 55-74 had the largest increase in alcohol/substance-related diagnoses (59% and 172%). Ages <18 had the largest increase in suicide-related diagnoses (287%). Overall, odds for current-year diagnosis were higher among men (adjusted OR (AOR) 1.49, 95% CI 1.47 to 1.51), and among those with Affordable Care Act or Medicare coverage relative to commercial coverage (AOR 1.30, 1.24 to 1.37; AOR 1.51, 1.46 to 1.55). CONCLUSIONS: Increasing clinical rates of disease of despair diagnoses largely mirror broader societal trends in mortality. While the opioid crisis remains a top public health priority, parallel rises in alcohol-related diagnoses and suicidality must be concurrently addressed. Findings suggest opportunities for healthcare systems and providers to deploy targeted prevention to mitigate the progression of morbidities towards mortality.

Comorbid PTSD and Depression Diagnoses Mediate the Association of Military Sexual Trauma and Suicide and Intentional Self-Inflicted Injury in VHA-Enrolled Iraq/Afghanistan Veterans, 2004-2014.

BACKGROUND: Exposure to military sexual trauma (MST) in veterans is associated with suicidal ideation. Previous research suggests there are mechanisms of this association, including posttraumatic stress disorder (PTSD) and depression. Research has yet to examine whether comorbid PTSD and depression mediate the association of MST and suicide and intentional self-inflicted injury, and whether this comorbidity confers a greater risk for suicide relative to PTSD-only and depression-only. The current study addressed this gap in our knowledge. METHODS: Screening results identifying MST exposure, PTSD and depression diagnoses, suicide and intentional self-inflicted injury, and demographic covariates in 435,690 Iraq/Afghanistan veterans were extracted from Veterans Health Administration (VHA) medical records. Veterans were included if they attended VHA from 2004-2014. Mediation was tested with path analyses. RESULTS: Suicide and intentional self-inflicted injury was observed in 16,149 (3.71%) veterans. The indirect effect of suicide and intentional self-inflicted injury, given a positive screen for MST, was highest among veterans with comorbid PTSD and depression diagnoses (indirect effect=3.18%, 95% confidence interval [CI] [3.01%, 3.32%]), with smaller probabilities observed for both PTSD-only (indirect effect=-0.18%, 95% CI [-0.20%, -0.14%]) and depression-only (indirect effect=0.56%, 95% CI [0.51%, 0.62%]; ps<.05). LIMITATIONS: Data were limited to VHA-enrolled Iraq/Afghanistan veterans. CONCLUSIONS: To reduce suicide risk among veterans with a history of MST, treatments may be most effective if they target comorbid PTSD and depression. Future research should examine the mechanisms through which comorbid PTSD and depression result in heightened risk for suicide and intentional self-inflicted injury.

Association of Health Conditions and Health Service Utilization With Intimate Partner Violence Identified via Routine Screening Among Middle-Aged and Older Women.

Importance: The US Preventive Services Task Force recently determined that there is insufficient evidence to recommend routine screening for intimate partner violence (IPV) in women who are middle-aged and older. Certain Veterans Health Administration (VHA) clinics have been routinely screening women of all ages for IPV since 2014. Objectives: To examine the proportion of women older than childbearing age (ie, ≥45 years) who have positive results when routinely screened for past-year IPV at VHA clinics and to evaluate the associations of a positive screening result with health conditions and health service utilization. Design, Setting, and Participants: This cohort study included 4481 women aged 45 years and older who were screened for past-year IPV in 13 VHA outpatient clinics in 11 states between April 2014 and April 2016. Data analysis was conducted from March 2019 to August 2019. Exposure: Positive screening result for past-year IPV. Main Outcomes and Measures: Mental and physical health conditions (identified using International Classification of Diseases, Ninth Edition [ICD-9] and ICD-10 codes from VHA medical record data) and VHA health services utilization (identified using inpatient and outpatient VHA encounter data) in the 20 months after screening. Results: In this study, 2937 of 4481 women (65.5%) were middle-aged (ie, aged 45 to 59 years), and 1544 (34.5%) were older (ie, aged ≥60 years), with 1955 (43.6%) black participants. A total of 255 middle-aged women (8.7%; mean [SD] age, 51 [4] years) and 79 older women (5.1%; mean [SD] age, 64 [5] years) screened positive for past-year IPV. In adjusted logistic regression models among middle-aged women, screening positive for IPV was associated with subsequent diagnoses of anxiety (adjusted odds ratio [aOR], 2.00; 95% CI, 1.50-2.70; P < .001), depression (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), posttraumatic stress disorder (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), suicidal ideation and/or behavior (aOR, 3.80; 95% CI, 2.10-6.90; P < .001), and substance use disorder (aOR, 2.50; 95% CI, 1.80-3.50; P < .001). Similar but attenuated associations were seen for older women (eg, substance use disorder: aOR, 2.20; 95% CI, 1.10-4.40; P = .04). In adjusted negative binomial regression models among middle-aged women, screening positive for IPV was associated with a higher rate of subsequent psychosocial (eg, mental health) visits (adjusted rate ratio [aRR], 2.40; 95% CI, 2.00-2.90; P < .001), primary care visits (aRR, 1.20; 95% CI, 1.10-1.30; P < .001), and emergency department visits (aRR, 1.50; 95% CI 1.20-1.80; P < .001). Older women screening positive for IPV had a higher rate of psychosocial visits (aRR, 1.90; 95% CI, 1.30-2.70; P < .001) but not of other visit types. Conclusions and Relevance: To our knowledge, this study was the largest to evaluate routine screening for IPV among women aged 45 years and older, and it found that IPV remained prevalent and was associated with morbidity for these women. Screening for IPV in women older than 44 years may improve detection and provision of evidence-based services to this growing population.

Gender moderates the association of military sexual trauma and risk for psychological distress among VA-enrolled veterans.

BACKGROUND: Military sexual trauma (MST) is associated with increased risk for posttraumatic stress disorder (PTSD) and depression diagnoses, as well as suicidal ideation/behavior (SI/B). Little is known about the differential effect of gender on the association of MST and the aforementioned mental health outcomes. As females are the fastest growing subpopulation of the Veterans Health Administration (VHA), it is imperative to assess possible between-gender differences in the association of MST with PTSD, depression, and SI/B. METHODS: Participants were 435,690 (n = 382,021, 87.7% men) 9/11 era veterans seen for care at the VHA between 2004 and 2014. Demographics, gender, PTSD and depression diagnoses, SI/B, and MST screen status were extracted from medical records. Adjusted logistic regression models assessed the moderating effect of gender on the association of MST with PTSD and depression diagnoses, as well as SI/B. RESULTS: Women with MST had a larger increased risk for a PTSD diagnosis (predicted probability =0.56, 95% confidence interval [CI] [0.56, 0.56]) and comparable risk for a depression diagnosis (predicted probability = 0.63, 95% CI [0.63, 0.64]) compared to men with MST. Men were more likely to have evidence of SI/B (predicted probability = 1.07, 95% CI [0.10, 0.11]) relative to women, but the interaction between gender and MST was nonsignificant. LIMITATIONS: Data were limited to veterans seeking care through VHA and the MST screen did not account for MST severity. CONCLUSIONS: Non-VHA settings may consider screening for MST in both men and women, given that risk for PTSD and depression is heightened among female survivors of MST.

Predicting and Planning for Musculoskeletal Service-Connected Disabilities in VA Using Disability for Active Duty OEF/OIF Military Service Members.

INTRODUCTION: Musculoskeletal (MSK) conditions are commonly seen among military service members (SM) and Veterans. We explored correlates of award of MSK-related service-connected disability benefits (SCDB) among SM seeking care in Veterans Affairs (VA) hospitals. MATERIALS AND METHODS: Department of Defense data on SM who separated from October 1, 2001 to May 2017 were linked to VA administrative data. Using adjusted logistic regression models, we determined the odds of receiving MSK SCDB. RESULTS: A total of 1,558,449 (79% of separating SM) had at least one encounter in VA during the study period (7.8% disability separations). Overall, 51% of this cohort had at least one MSK SCDB (88% among disability separations, 48% among normal). Those with disability separations (as compared to normal separations) were significantly more likely to receive MSK SCDB (odds ratio 2.37) as were females (compared to males, odds ratio 1.15). CONCLUSIONS: Although active duty SM with disability separations were more likely to receive MSK-related service-connected disability ratings in the VA, those with normal separations also received such awards. Identifying those at highest risk for MSK-related disability could lead to improved surveillance and prevention strategies in the Department of Defense and VA health care systems to prevent further damage and disability.

Exploring Disparities in Awarding VA Service-Connected Disability for Post-Traumatic Stress Disorder for Active Duty Military Service Members from Recent Conflicts in Iraq and Afghanistan.

INTRODUCTION: We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation. METHODS: Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data. Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD. RESULTS: A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations). Females (OR 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis (OR 0.97, 1.01). Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17). CONCLUSIONS: Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards. Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.

Comparison of Skin Biomechanics and Skin Color in Puerto Rican and Non-Puerto Rican Women.

OBJECTIVE: Skin biomechanics are physical properties that protect the body from injury. Little is known about differences in skin biomechanics in racial/ethnic groups and the role of skin color in these differences. The purpose of this study was to determine the relationship between skin biomechanics (viscoelasticity, hydration) and skin color, when controlling for demographic and health-related variables in a sample of Puerto Rican and non-Puerto Rican women. METHODS: We performed a secondary analysis of data from 545 women in a longitudinal, observational study of skin injury in Puerto Rico and the United States. Data included measures of skin viscoelasticity, skin hydration, skin color, demographic, and health related variables. Skin color was measured by spectrophotometry (L* - lightness/darkness, a*- redness/greenness, b* - yellowness/blueness). The sample was 12.5% Puerto Rican, 27.3% non-Puerto Rican Latina, 28.8% Black, 28.6% White, and 2.8% Other. RESULTS: Regression analyses showed that: 1) higher levels of skin viscoelasticity were associated with lower age, higher BMI, and identifying as non-Puerto Rican Latina as compared to Puerto Rican; (all p < .001); and 2) higher levels of hydration were associated with lower L* values, higher health status, lower BMI, and identifying as non-Puerto Rican Latina, White, or Other as compared to Puerto Rican (all p < .05). CONCLUSION: When adjusting for skin color, Puerto Rican women had lower viscoelasticity and hydration as compared to other groups. Puerto Rican women may be at long-term risk for skin alterations, including pressure injury, as they age or become chronically ill.

Understanding rates of genital-anal injury: Role of skin color and skin biomechanics.

PURPOSE: A series of studies suggest that non-Hispanic White women have significantly more injuries than non-Hispanic Black women after sexual assault and consensual sexual intercourse. One explanation for this difference is that the degree of skin protection may vary as skin mechanics and skin pigmentation vary. The aim of the study was to determine the association among genital-anal injury, skin color, skin viscoelasticity and skin hydration in women following consensual sexual intercourse when controlling for age, smoking history, body mass index (BMI), sun exposure, and health status. PROCEDURES: We employed a prospective cohort study design to enroll women 21 years of age or older at two study sites. They underwent two data collection sessions, baseline and follow-up after consensual sexual intercourse. Baseline genital-anal injury identification occurred with a standard forensic examination (direct visualization, nuclear staining with toluidine blue contrast, and colposcopy examination) and measurements of other variables (skin color, skin viscoelasticity, skin hydration, age, smoking history, body mass index [BMI], sun exposure, and health status). Participants were then asked to have consensual sexual intercourse with a male partner of their choice and to return for a second forensic examination for injury detection. Genital-anal injury was regressed on skin color, skin viscoelasticity, skin hydration, age, smoking history, BMI, sun exposure, and health status. FINDINGS: We enrolled 341 participants, 88 non-Hispanic White (25.8%), 54 non-Hispanic Black (15.8%), 190 Hispanic/Latina (55.7), and 9 Other Identities (2.6%). At baseline the genital-anal injury prevalence was 57.77% and at follow-up after consensual sexual intercourse, injury prevalence was 72.73%. External genital injury prevalence was associated with increased L* (lightness) values (Adjusted Odds Ratio [AOR] = 1.98, 95% Confidence Interval [CI] = 1.03, 4.04) and decreased skin elasticity (AOR = 0.96, 95% CI = 0.93, 0.99) at baseline. Increased skin hydration was associated with a significantly higher frequency of external, internal, anal, and total genital-anal injuries (Adjusted Rate Ratio [ARR] > 1.27) at follow-up. Also at the follow-up examination, Hispanic/Latina participants had significantly lower external genital and total genital-anal injury prevalence and frequency as compared to non-Hispanic White participants (AOR < 0.40). CONCLUSIONS: Our findings provide qualified support for the importance of skin color during the forensic examination. Women with lighter skin tones may have skin that is more easily injured than women with darker tones. In contrast, external genital injuries may be more easily identified in women with light as compared to dark skin, a situation that is important in both the health care and criminal justice systems. Additionally, women with decreased viscoelasticity and increased hydration may be more easily injured. These findings support the need to develop forensic procedures that are effective in people across the range of skin colors and to interpret forensic findings considering the innate properties of the skin.

A positive screen for military sexual trauma is associated with greater risk for substance use disorders in women veterans.

Military sexual trauma (MST) is a significant public health issue associated with adverse psychiatric outcomes, including heightened risk for suicide, posttraumatic stress disorder, depression, and substance use disorders. Recently, research has begun exploring gender-linked disparities in mental health outcomes for individuals who experience MST. The current study assessed whether women who screened positive for MST were at disproportionately higher risk for diagnoses of alcohol-use disorder (AUD) or drug-use disorder (DUD) relative to men. Veterans Health Administration (VHA) clinical data were extracted for 435,690 military veterans who separated from the military between 2004 and 2011 and had at least 5 years of follow-up data after their initial VHA visit until the end of fiscal year 2014. Logistic regression models examined the main and interactive effects of gender and screening positively for MST as predictors of AUD and DUD. MST positive screens were associated with increased rates of both AUD and DUD across genders. Although rates of both AUD and DUD were higher among men, the increased rate of diagnosis associated with MST positive screens was proportionally higher for women than men (interaction adjusted odds ratios = 1.43 and 1.17 for AUD and DUD, respectively), indicating the presence of a gender-linked health risk disparity. This disparity was more pronounced for AUD than DUD (p < .01). The current study adds to previous literature documenting increased risk for women exposed to MST. These findings support efforts to reduce the occurrence of MST and continued use of MST screening measures within the VHA. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Combining Natural Language Processing of Electronic Medical Notes With Administrative Data to Determine Racial/Ethnic Differences in the Disclosure and Documentation of Military Sexual Trauma in Veterans.

BACKGROUND: Despite national screening efforts, military sexual trauma (MST) is underreported. Little is known of racial/ethnic differences in MST reporting in the Veterans Health Administration (VHA). OBJECTIVE: This study aimed to compare patterns of MST disclosure in VHA by race/ethnicity. RESEARCH DESIGN: Retrospective cohort study of MST disclosures in a national, random sample of Veterans who served in Afghanistan and Iraq and completed MST screens from October 2009 to 2014. We used natural language processing (NLP) to extract MST concepts from electronic medical notes in the year following Veterans' first MST screen. MEASURE(S): Any evidence of MST (positive MST screen or NLP concepts) and late MST disclosure (NLP concepts following a negative MST screen). Multivariable logistic regressions, stratified by sex, tested racial/ethnic differences in any MST evidence, and late disclosure. RESULTS: Of 6618 male and 6716 female Veterans with MST screen results, 1473 had a positive screen (68 male, 1%; 1405 female, 21%). Of those with a negative screen, 257 evidenced late MST disclosure by NLP (44 male, 39%; 213 female, 13%). Late MST disclosure was usually documented during mental health visits. There were no significant racial/ethnic differences in MST disclosure among men. Among women, blacks were less likely than whites to have any MST evidence (adjusted odds ratio=0.75). In the subsample with any MST evidence, black and Hispanic women were more likely than whites to disclose MST late (adjusted odds ratio=1.89 and 1.59, respectively). CONCLUSIONS: Combining NLP results with MST screen data facilitated the identification of under-reported sexual trauma experiences among men and racial/ethnic minority women.

VHA-Enrolled Homeless Veterans Are at Increased Risk for Eating Disorder Diagnoses.

Introduction: Veterans are overrepresented in the U.S. homeless population, comprising 8.6% of the general U.S. population, but 14% of the homeless population. Homeless veterans have several risk factors for eating disorder diagnoses, but the association of homelessness and eating disorders in this population is understudied. Given limited access to adequate food given their diminished resources, it is critical to better understand risk for eating disorders as a function of homelessness. Materials and Methods: Administrative data on homelessness, eating disorder diagnoses, and related comorbidities occurring within the first 5 years of Veterans Health Administration (VHA) healthcare utilization between 2004 and 2014 in 265,806 Iraq/Afghanistan veterans were extracted from VHA medical records. Logistic regression analysis estimated the risk for eating disorders as a function of homelessness while accounting for demographic, military, and mental health covariates. Results: Homelessness was observed in 11,876 veterans (4.5%), and of these, 71 (0.6%) had an eating disorder diagnosis. Odds of having an eating disorder diagnosis were 59% higher (adjusted odds ratio = 1.59, 95% confidence interval [1.21-2.09]) among homeless veterans relative to domiciled veterans. Conclusions: A diagnosis of eating disorders in veterans is rare at the VHA, however, the current study found that homelessness may increase risk for eating disorders in this population. Unique strategies to provide evidenced-based care while accounting for inadequate daily resources are needed to reduce the risk of eating disorders in this population.

Regional Variations in Documentation of Sexual Trauma Concepts in Electronic Medical Records in the United States Veterans Health Administration.

Background: Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). Objective: To describe variations in how sexual trauma is documented in the Veterans Health Adminstration's EHR. Methods: Sexual trauma concepts were extracted from from 362,559 clinical notes using a natural language processing pipeline. Results: We observed variations in the presence of sexual trauma in notes across five United States regions: Pacific, Continental, Midwest, North Atlantic, Southeast. We also observed variations in the types of notes used to document sexual trauma (e.g., mental health, primary care) and sources of sexual trauma (e.g., adult, childhood, military) mentioned in the EHR. Our findings illustrate potential differences in cultural norms related to patient disclosure of sensitive information, and provider documentation. Standardized protocol for eliciting and documenting sexual trauma histories are needed to ensure Veteran access to high quality, trauma-informed care.

Suicidal ideation and behaviors among women veterans with recent exposure to intimate partner violence.

OBJECTIVE: Women veterans have disproportionately high risk for both suicide and intimate partner violence compared to women non-veterans. The objective of this study was to assess the relationship between intimate partner violence (IPV) and suicidal ideation and suicidal or self-harm behaviors among women veterans. METHOD: Veterans Health Administration (VHA) electronic medical records were extracted for 8427 women veterans who completed screening for past-year IPV between April 2014 and 2016. Risk for suicidal ideation and self-harm behaviors were estimated as function of screening results using logistic regression. RESULTS: Overall, 8.4% screened positive for IPV. Suicidal ideation or self-harm behaviors were recorded for 3.2%. Positive IPV screen was associated with double the odds for suicidal ideation (AOR = 2.04; 95% CI = 1.47-2.86) and self-harm behaviors (AOR = 2.05, 95% CI = 1.10-3.83). Risks did not significantly differ by IPV type. Suicide-related ICD codes were most often recorded prior to IPV screening. CONCLUSIONS: There is a strong association between positive IPV screen and suicidal ideation and self-harm behaviors among VHA-engaged women veterans. Documentation of either event is an important marker for the other. Integration of suicide prevention with IPV services may enhance identification of women at risk and speed service uptake. Suicidal ideation and behaviors should be assessed among women with positive IPV screens, and identification of suicide risk should trigger IPV assessment.

Chronic Health Conditions Among US Veterans Discharged From Military Service for Misconduct.

Veterans who are discharged from military service due to misconduct are vulnerable to negative health-related outcomes, including homelessness, incarceration, and suicide. We used national data from the Veterans Health Administration for 218,608 veterans of conflicts in Iraq and Afghanistan that took place after the events of September 11, 2001, to compare clinical diagnoses between routinely-discharged (n = 203,174) and misconduct-discharged (n = 15,433) veterans. Misconduct-discharged veterans had significantly higher risk for all mental health conditions (adjusted odds ratio [AOR] range, 2.5-8.0) and several behaviorally linked chronic health conditions (AOR range, 1.2-5.9). Misconduct-discharged veterans have serious and complex health care needs; prevention efforts should focus on behavioral risk factors to prevent the development and exacerbation of chronic health conditions among this vulnerable population.

Applying Machine Learning to Linked Administrative and Clinical Data to Enhance the Detection of Homelessness among Vulnerable Veterans.

U.S. military veterans who were discharged from service for misconduct are at high risk for homelessness. Stratifying homelessness risk based on both military service factors and clinical characteristics could facilitate targeted provision of preventive services to those at critical risk. Using administrative data from the Department of Defense and Veterans Health Administration for 25,821 misconduct-discharged Veterans, we developed a dataset that included demographic and clinical characteristics corresponding to 12-months, 3-months, and 1-month preceding the first documentation of homelessness (or a matched index encounter for those without homelessness). Clinical time-trend features were extracted and included as additional model inputs. We developed several random forest models to classify homelessness risk. Models based on 1- and 3-months of data performed roughly as well as those based on 12-months of data. In best-performing models, 70% of those identified as at high-risk became homeless; 30% identified as at moderate risk became homeless (AUC=0.80; recall=0.64, specificity=0.82). Findings suggest the viability of risk stratification for targeting resources.