Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset.

BACKGROUND: The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness. OBJECTIVE: To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic. DESIGN: Retrospective cohort study, 3/16/2019-3/15/2022. PARTICIPANTS: 394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits. MAIN MEASURES: The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing). KEY RESULTS: Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42-0.44), women (OR = 1.74, CI: 1.70-1.78), Black (OR = 1.14, CI: 1.12-1.16), Hispanic (OR = 1.34, CI: 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services. CONCLUSIONS: Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.

Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease.

BACKGROUND: Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered. OBJECTIVE: Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension. DESIGN: Retrospective cohort study. PATIENTS: Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years. MAIN MEASURES: The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering. KEY RESULTS: Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06). CONCLUSIONS: Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Telehealth Complementary and Integrative Health Therapies During COVID-19 at the U.S. Department of Veterans Affairs.

Background: Complementary and integrative health (CIH) therapies, such as in-person acupuncture, chiropractic care, and meditation, are evidence-based nonpharmaceutical treatment options for pain. During COVID-19, the Veterans Health Administration (VA) delivered several CIH therapies virtually. This study explores veterans' utilization, advantages/disadvantages, and delivery issues of yoga, Tai Chi, meditation/mindfulness (self-care), and massage, chiropractic, and acupuncture (practitioner-delivered care), using telephone/video at 18 VA sites during COVID-19. Methods: Use of virtual care was examined quantitatively with VA administrative data for six CIH therapies before and after COVID-19 onset (2019-2021). Advantages/disadvantages and health care delivery issues of these CIH therapies through virtual care were examined qualitatively using interview data (2020-2021). Results: Overall, televisits represented a substantial portion of all CIH self-care therapies delivered by VA in 2020 (53.7%) and 2021 (82.1%), as sites developed virtual group classes using VA secure online video platforms in response to COVID-19. In contrast, a small proportion of all encounters with acupuncturists, chiropractors, and massage therapists was telephone/video encounters in 2020 (17.3%) and in 2021 (5.4%). These were predominantly one-on-one care in the form of education, follow-ups, home exercises, assessments/evaluations, or acupressure. Delivery issues included technical difficulties, lack of access to needed technology, difficulty tracking virtual visits, and capacity restrictions. Advantages included increased access to self-care, increased patient receptivity to engaging in self-care, and flexibility in staffing online group classes. Disadvantages included patient preference, patient safety, and strain on staffing. Conclusion: Despite delivery issues or disadvantages of tele-CIH self-care, veterans' use of teleself-care CIH therapies grew substantially during the COVID-19 pandemic.

Disaster Preparedness Training Needs of Healthcare Workers at the US Department of Veterans Affairs.

OBJECTIVES: Training healthcare workers in disaster preparedness has been shown to increase their willingness and ability to report to work during disasters. Little is known, however, about the relation between sociodemographic, household, and workforce characteristics and the desire for such training. Accordingly, this study aimed to assess healthcare workers' desire for additional workforce preparedness training, and the determinants that influence the need for such training, for three types of disasters (natural, pandemic, manmade). METHODS: The US Department of Veterans Affairs (VA) Preparedness Survey was a random, anonymous, Web-based questionnaire fielded nationwide (October-December 2018). Multivariate, logistic regression analyses were conducted. RESULTS: In total, 4026 VA employees, clinical and nonclinical, responded. A total of 61% of respondents wanted additional training for natural, 63% for pandemic, and 68% for manmade disasters. VA supervisors (natural: odds ratio [OR] 1.28, pandemic: OR 1.33, manmade: OR 1.25, P < 0.05) and clinicians (natural: OR 1.24, pandemic: OR 1.24, manmade: OR 1.24, P < 0.05) were more likely to report the need for additional training. Those who reported that they understood their role in disaster response were less likely to report the need for training (natural: OR 0.25, pandemic: OR 0.27, manmade: OR 0.28, P < 0.001), whereas those who perceived their role to be important during response (natural: OR 2.20, pandemic: OR 2.78, manmade: OR 3.13, P < 0.001), and those who reported not being prepared at home for major disasters (natural: OR 1.85, pandemic: OR 1.92, manmade: OR 1.94, P < 0.001), were more likely to indicate a need for training. CONCLUSIONS: Identifying which factors encourage participation in disaster preparedness training can help hospitals and other healthcare providers create targeted training and educational materials to better prepare all hospital staff for future disasters.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States.

INTRODUCTION: The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence. METHODS: We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights. RESULTS: Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States. DISCUSSION: By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Managing the unexpected: The role of homeless service providers during the 2017-2018 California wildfires.

People experiencing homelessness during the 2017-2018 California wildfires faced significant risks of disruption. Homeless service organizations (HSOs) are an essential safety net for this population. To learn about how HSOs performed during the wildfires, this study interviewed U.S. Department of Veterans Affairs (VA) staff overseeing HSOs providing transitional housing under the VA's Grant and Per Diem (GPD) program to Veterans experiencing homelessness. We employed a comparative case study approach exploring GPD organizations' disaster response actions, including evacuating Veterans from wildfire-affected areas or taking in disaster-displaced Veterans. This article presents three themes in the GPD organizations' disaster response: (1) Organizations benefitted from close collaboration and communication with the VA during the disaster, creating a safety net to ensure Veterans' well-being and enact rapid re-housing to prevent homelessness; (2) Organization staff performed heroically under stressful disaster conditions; and (3) Organizations benefitted from the written disaster plans that VA requires them to create, but were not as well-prepared for wildfires as they had been for earthquakes. As emergent threats such as the COVID-19 pandemic, wildfires, and a very active 2020 hurricane season amplify the importance of mitigating risks, comprehensive disaster planning is needed to ensure the safety and support of people experiencing homelessness.

Workforce preparedness for disasters: perceptions of clinical and non-clinical staff at the U.S. Department of Veterans Affairs.

BACKGROUND: Most U.S. studies on workforce preparedness have a narrow scope, focusing primarily on perceptions of clinical staff in a single hospital and for one type of disaster. In contrast, this study compares the perceptions of workplace disaster preparedness among both clinical and non-clinical staff at all U.S. Department of Veterans Affairs (VA) medical facilities nationwide for three types of disasters (natural, epidemic/pandemic, and manmade). METHODS: The VA Preparedness Survey used a stratified simple random, web-based survey (fielded from October through December 2018) of all employees at VA medical facilities. We conducted bivariate and multivariate logistic regression analyses to compare the sociodemographic characteristics and perceptions of disaster preparedness between clinical and non-clinical VA staff. RESULTS: The study population included 4026 VA employees (2488 clinicians and 1538 non-clinicians). Overall, VA staff were less confident in their medical facility's ability to respond to epidemic/pandemics and manmade disasters. Depending on the type of disaster, clinical staff, compared to non-clinical staff, were less likely to be confident in their VA medical facility's ability to respond to natural disasters (OR:0.78, 95% CI:0.67-0.93, p < 0.01), pandemics (OR:0.82, 95% CI:0.70-0.96, p < 0.05), and manmade disasters (OR: 0.74, 95% CI: 0.63-0.86, p < 0.001). On the other hand, clinicians, compared to non-clinicians, were 1.45 to 1.78 more likely to perceive their role in disaster response to be important (natural OR:1.57, 95% CI:1.32-1.87; pandemic OR:1.78, 95% CI:1.51-2.10; manmade: OR:1.45; 95% CI: 1.23-1.71; p's < 0.001), and 1.27 to 1.29 more likely to want additional trainings to prepare for all three types of disasters (natural OR:1.29, 95% CI:1.10-1.51; pandemic OR:1.27, 95% CI:1.08-1.49; manmade OR:1.29; 95% CI:1.09-1.52; p's < 0.01). Clinicians were more likely to be women, younger, and more educated (p's < 0.001) than non-clinicians. Compared to clinicians, non-clinical staff had been employed longer with the VA (p < 0.025) and were more likely to have served in the U.S. Armed Forces (p < 0.001). CONCLUSIONS: These findings suggest both a desire and a need for additional training, particularly for clinicians, and with a focus on epidemics/pandemics and manmade disasters. Training programs should underscore the importance of non-clinical roles when responding to disasters.

Preparedness and response activities of the US Department of Veterans Affairs (VA) home-based primary care program around the 2017 hurricane season.

BACKGROUND: Large-scale natural disasters disproportionally affect both the medically complex and the older old, groups that are responsible for most medical surge after a disaster. To understand how to ameliorate this surge, we examined the activities of the nine US Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) programs impacted during the 2017 Fall Hurricane Season. METHODS: Convergent mixed methods design, incorporating independently conducted qualitative and quantitative analyses. Phase One: 34 clinical staff were interviewed from the nine VA HBPC programs impacted by Hurricanes Harvey, Irma, and Maria to examine the experiences of their HBPC programs in response to the Hurricanes. Phase Two: Secondary quantitative data analysis used the VA's Corporate Data Warehouse (CDW) to examine the electronic health records of patients for these same nine sites. RESULTS: The emergency management activities of the HBPC programs emerged as two distinct phases: preparedness, and response and recovery. The early implementation of preparedness procedures, and coordinated post-Hurricane patient tracking, limited disruption in care and prevented significant hospitalizations among this population. CONCLUSIONS: Individuals aged 75 or older, who often present with multiple comorbidities and decreased functional status, typically prefer to age in their homes. Additionally, as in-home medical equipment evolves, more medically vulnerable individuals are able to receive care at home. HBPC programs, and similar programs under Medicare, connect the homebound, medically complex, older old to the greater healthcare community. Engaging with these programs both pre- and post-disasters is central to bolstering community resilience for these at-risk populations.

General household emergency preparedness: a comparison between veterans and nonveterans.

BACKGROUND: Despite federal and local efforts to educate the public to prepare for major emergencies, many US households remain unprepared for such occurrences. United States Armed Forces veterans are at particular risk during public health emergencies as they are more likely than the general population to have multiple health conditions. METHODS: This study compares general levels of household emergency preparedness between veterans and nonveterans by focusing on seven surrogate measures of household emergency preparedness (a 3-day supply of food, water, and prescription medications, a battery-operated radio and flashlight, a written evacuation plan, and an expressed willingness to leave the community during a mandatory evacuation). This study used data from the 2006 through 2010 Behavioral Risk Factor Surveillance System (BRFSS), a state representative, random sample of adults aged 18 and older living in 14 states. RESULTS: The majority of veteran and nonveteran households had a 3-day supply of food (88% vs 82%, respectively) and prescription medications (95% vs 89%, respectively), access to a working, battery-operated radio (82% vs 77%, respectively) and flashlight (97% vs 95%, respectively), and were willing to leave the community during a mandatory evacuation (91% vs 96%, respectively). These populations were far less likely to have a 3-day supply of water (61% vs 52%, respectively) and a written evacuation plan (24% vs 21%, respectively). After adjusting for various sociodemographic covariates, general health status, and disability status, households with veterans were significantly more likely than households without veterans to have 3-day supplies of food, water, and prescription medications, and a written evacuation plan; less likely to indicate that they would leave their community during a mandatory evacuation; and equally likely to have a working, battery-operated radio and flashlight. CONCLUSION: These findings suggest that veteran households appear to be better prepared for emergencies than do nonveteran households, although the lower expressed likelihood of veterans households to evacuate when ordered to do so may place them at a somewhat greater risk of harm during such events. Further research should examine household preparedness among other vulnerable groups including subgroups of veteran populations and the reasons why their preparedness may differ from the general population.

Pre-earthquake burden of illness and postearthquake health and preparedness in veterans.

BACKGROUND: During an earthquake, vulnerable populations, especially those with chronic conditions, are more susceptible to adverse, event-induced exacerbation of chronic conditions such as limited access to food and water, extreme weather temperatures, and injury. These circumstances merit special attention when health care facilities and organizations prepare for and respond to disasters. METHODS: This study explores the relationship between pre-earthquake burden of illness and post earthquake health-related and preparedness factors in the US. Data from a cohort of male veterans who were receiving care at the Sepulveda Veterans Affairs Medical Center (VAMC) in Los Angeles, California USA during the 1994 Northridge earthquake were analyzed. RESULTS: Veterans with one or more chronic conditions were more likely to report pain lasting two or more days, severe mental/emotional stress for more than two weeks, broken/lost medical equipment, having difficulty refilling prescriptions, and being unable to get medical help following the quake compared to veterans without chronic conditions. In terms of personal emergency preparedness, however, there was no association between burden of illness and having enough food or water for at least 24 hours after the earthquake. CONCLUSION: The relationship that exists between health care providers, including both individual providers and organizations like the US Department of Veterans Affairs (VA), and their vulnerable, chronically-ill patients affords providers the unique opportunity to deliver critical assistance that could make this vulnerable population better prepared to meet their post disaster health-related needs. This can be accomplished through education about preparedness and the provision of easier access to medical supplies. Disaster plans for those who are burdened with chronic conditions should meet their social needs in addition to their psychological and physical needs.

Predictors of Acute Kidney Injury (AKI) among COVID-19 Patients at the US Department of Veterans Affairs: The Important Role of COVID-19 Vaccinations.

BACKGROUND: There are knowledge gaps about factors associated with acute kidney injury (AKI) among COVID-19 patients. To examine AKI predictors among COVID-19 patients, a retrospective longitudinal cohort study was conducted between January 2020 and December 2022. Logistic regression models were used to examine predictors of AKI, and survival analysis was performed to examine mortality in COVID-19 patients. RESULTS: A total of 742,799 veterans diagnosed with COVID-19 were included and 95,573 were hospitalized within 60 days following COVID-19 diagnosis. A total of 45,754 developed AKI and 28,573 AKI patients were hospitalized. Use of vasopressors (OR = 14.73; 95% CL 13.96-15.53), history of AKI (OR = 2.22; CL 2.15-2.29), male gender (OR = 1.90; CL 1.75-2.05), Black race (OR = 1.62; CL 1.57-1.65), and age 65+ (OR = 1.57; CL 1.50-1.63) were associated with AKI. Patients who were vaccinated twice and boosted were least likely to develop AKI (OR = 0.51; CL 0.49-0.53) compared to unvaccinated COVID-19 patients. Patients receiving two doses (OR = 0.77; CL = 0.72-0.81), or a single dose (OR = 0.88; CL = 0.81-0.95) were also less likely to develop AKI compared to the unvaccinated. AKI patients exhibited four times higher mortality compared to those without AKI (HR = 4.35; CL 4.23-4.50). Vaccinated and boosted patients had the lowest mortality risk compared to the unvaccinated (HR = 0.30; CL 0.28-0.31). CONCLUSION: Use of vasopressors, being unvaccinated, older age, male gender, and Black race were associated with post COVID-19 AKI. Whether COVID-19 vaccination, including boosters, decreases the risk of developing AKI warrants additional studies.

Implementation of Video-Based Care in Interdisciplinary Primary Care Settings at the Veterans Health Administration: Qualitative Study.

BACKGROUND: With the rapid shift to telehealth, there remains a knowledge gap in how video-based care is implemented in interdisciplinary primary care (PC) settings. OBJECTIVE: The objective of this study was to gain an in-depth understanding of how video telehealth services were implemented in PC from the perspectives of patients and interdisciplinary PC team members at the Veterans Health Administration (VHA) 2 years after the onset of the COVID-19 pandemic. METHODS: We applied a positive and negative deviance approach and selected the 6% highest (n=8) and the 6% lowest (n=8) video-using PC sites in 2022 from a total of 130 VHA medical centers nationally. A total of 12 VHA sites were included in the study, where 43 PC interdisciplinary team members (August-October 2022) and 25 patients (February-May 2023) were interviewed. The 5 domains from the diffusion of innovation theory and the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework guided the development of the 2 study interview guides (provider and patient). We identified themes that emerged across all interviews that were associated with the implementation of video-based care in interdisciplinary PC settings, using directed-content rapid analysis of the interview transcripts. The analysis was guided by 5 a priori NASSS domains: (1) patient condition or characteristic, (2) technology, (3) adopter system, (4) health care organization, and (5) adaptation over time. RESULTS: The study findings include the following common themes and factors, organized by the 5 NASSS domains: (1) patient condition or characteristic-visit type or purpose (eg, follow-up visits that do not require physical examination), health condition (eg, homebound or semihomebound patients), and sociodemographic characteristic (eg, patients who have a long commute time); (2) technology-key features (eg, access to video-enabled devices), knowledge (eg, how to use videoconferencing software), and technical support for patients and providers; (3) adopter system-changes in staff roles and clinical practice (eg, coordination of video-based care), provider and patient preference or comfort to use video-based care, and caregiver's role (eg, participation of caregivers during video visits); (4) health care organization-leadership support and access to resources, scheduling for video visits (eg, schedule or block off digital half or full days), and training and telehealth champions (eg, hands-on or on-site training for staff, patients, or caregivers); (5) adaptation over time-capacity to improve all aspects of video-based care and provide continued access to resources (eg, effective communication about updates). CONCLUSIONS: This study identified key factors associated with the implementation of video-based services in interdisciplinary PC settings at the VHA from the perspectives of PC team members and patients. The identified multifaceted factors may inform recommendations on how to sustain and improve the provision of video-based care in VHA PC settings as well as non-VHA patient-centered medical homes.

Measuring Patient-Reported Use and Outcomes From Complementary and Integrative Health Therapies: Development of the Complementary and Integrative Health Therapy Patient Experience Survey.

Background: Assessing the use and effectiveness of complementary and integrative health (CIH) therapies via survey can be complicated given CIH therapies are used in various locations and formats, the dosing required to have an effect is unclear, the potential health and well-being outcomes are many, and describing CIH therapies can be challenging. Few surveys assessing CIH therapy use and effectiveness exist, and none sufficiently reflect these complexities. Objective: In a large-scale Veterans Health Administration (VA) quality improvement effort, we developed the "Complementary and Integrative Health Therapy Patient Experience Survey", a longitudinal, electronic patient self-administered survey to comprehensively assess CIH therapy use and outcomes. Methods: We obtained guidance from the literature, subject matter experts, and Veteran patients who used CIH therapies in designing the survey. As a validity check, we completed cognitive testing and interviews with those patients. We conducted the survey (March 2021-April 2023), inviting 15,608 Veterans with chronic musculoskeletal pain with a recent CIH appointment or referral identified in VA electronic medical records (EMR) to participate. As a second validity check, we compared VA EMR data and patient self-reports of CIH therapy utilization a month after survey initiation and again at survey conclusion. Results: The 64-item, electronic survey assesses CIH dosing (amount and timing), delivery format and location, provider location, and payor. It also assesses 7 patient-reported outcomes (pain, global mental health, global physical health, depression, quality of life, stress, and meaning/purpose in life), and 3 potential mediators (perceived health competency, healthcare engagement, and self-efficacy for managing diseases). The survey took 17 minutes on average to complete and had a baseline response rate of 45.3%. We found high degrees of concordance between self-reported and EMR data for all therapies except meditation. Conclusions: Validly assessing patient-reported CIH therapy use and outcomes is complex, but possible.

PTSD risk and mental health care engagement in a multi-war era community sample of women veterans.

BACKGROUND: Post-traumatic stress disorder (PTSD) is common in women veterans (WVs), and associated with significant co-morbidity. Effective treatment is available; however, PTSD is often unrecognized. OBJECTIVES: Identify PTSD prevalence and mental healthcare (MHC) use in a representative national WV sample. DESIGN AND PARTICIPANTS: Cross-sectional, population-based 2008-2009 national survey of 3,611 WVs, weighted to the population. MAIN MEASURES: We screened for PTSD using a validated instrument, and also assessed demographic characteristics, health characteristics, and MHC use in the prior 12 months. Among those screening positive, we conducted multivariate logistic regression to identify independent predictors of MHC use. KEY RESULTS: Overall, 13.0 % (95 % confidence interval [CI] 9.8-16.2) of WVs screened PTSD-positive. Veterans Health Administration (VA) healthcare was used by 31.1 % of PTSD-positives and 11.4 % of PTSD-negatives (p<0.001). Among those screening positive, 48.7 % (95 % CI 35.9-61.6) used MHC services (66.3 % of VA-users, 40.8 % of VA-nonusers; p<0.001). Having a diagnosis of depression (OR=8.6; 95 % CI 1.5-48.9) and VA healthcare use (OR=2.7; 95 % CI 1.1-7.0) predicted MHC use, whereas lacking a regular provider for health care (OR=0.2; 95 % CI 0.1-0.4) and household income below the federal poverty level (OR=0.2; 95 % CI 0.1-0.5) predicted nonuse. CONCLUSIONS: More than one in eight WVs screened positive for PTSD. Though a majority of VA-users received MHC, low income predicted nonuse. Only a minority of VA-nonusers received MHC. The majority of WVs use non-VA healthcare providers, who may be unaware of their veteran status and PTSD risk. VA outreach to educate VA-nonusers and their healthcare providers about WVs' PTSD risk and available evidence-based VA treatment options is one approach to extend the reach of VA MHC. Research to characterize barriers to VA MHC use for VA-nonusers and low income VA-users is warranted to better understand low service utilization, and to inform program development to engage more WVs in needed MHC.

Health-related quality of life and comorbidity among older women veterans in the United States.

PURPOSE: This paper examines the predictors of quality of life among older women (≥65 years of age) veterans in the United States focusing on the effect of comorbidity on health-related quality of life (HRQOL). METHODS: Data from the National Survey of Women Veterans, a cross-sectional nationally representative population-based, stratified random sample of women veterans, were used with an analytic sample size of 1,379 older women veterans. The SF12 physical and mental composite scores (PCS and MCS) were used as outcome measures, and a weighted comorbidity index was used as a covariate. RESULTS: Older women veterans who are married, employed, with higher income, and higher education have better physical health (PCS). For mental health, education is positively correlated, whereas depression and posttraumatic stress disorder are negatively correlated with MCS. After adjusting for socio-demographic, mental health, and chronic health indicators, the results showed that SF12 PCS varied by VA use status for each level of Seattle Index of Comorbidity. The same pattern was not found for MCS. CONCLUSION: For each level of comorbidity, VA users have worse HRQOL which might suggest that case mix adjustments comparing VA users and non-VA users must take into account more than comorbidity alone.

Comparison of the use of H1N1 and seasonal influenza vaccinations between veterans and non-veterans in the United States, 2010.

BACKGROUND: Veterans of the U.S. armed forces tend to be older and have more chronic health problems than the general adult population, which may place them at greater risk of complications from influenza. Despite Centers for Disease Control and Prevention (CDC) recommendations, seasonal influenza vaccination rates for the general adult population remain well below the national goal of 80%. Achieving this goal would be facilitated by a clearer understanding of which factors influence vaccination. METHODS: Using the 2010 U.S. National Health Interview Survey (NHIS), this study estimates models of two types of vaccinations (H1N1 and seasonal flu), assesses if the correlates differ for these vaccinations, and analyses the distribution of the correlates by veteran status. RESULTS: Veterans, women, non-Hispanic whites, non-smokers, those at high risk, educated, with health insurance, and who use clinics as a usual source of care were more likely to receive both types of vaccinations. Those who were older, married, and with higher income were more likely to get vaccinated for seasonal flu, but not for H1N1. Age and number of children living in the household were found to have different effects for H1N1 compared to seasonal flu. CONCLUSION: Veterans are more likely to get vaccinated for seasonal influenza and H1N1 compared to the general population. This might be due to Veterans having better access to care or Veterans participating in better health care practices. Future studies should examine potential differences in flu vaccination use among Veterans using Veterans Affairs (VA) health care system vs. non-VA users.

The role of military social support in understanding the relationship between PTSD, physical health, and healthcare utilization in women veterans.

Posttraumatic stress disorder (PTSD) is a significant predictor of both poorer physical health and increased health care utilization, whereas adequate social support is associated with better physical health and less health care utilization. However, research has not previously examined the simultaneous effects of PTSD and social support on health and health care utilization. This study examined both the independent and interactive effects of PTSD and a particular type of social support (postactive-duty social support from military friends) on self-reported physical health and number of Veterans Health Administration (VHA) visits in the last year. These relationships were examined in a representative, national sample of 3,524 women veterans who completed telephone interviews as part of the National Survey of Women Veterans in 2008-2009. Regression analyses were conducted using these cross-sectional data to examine main effects of PTSD and military social support on physical health and VHA utilization and their interaction. Screening positive for PTSD was associated with poorer health (B = -3.19, SE = 1.47) and increased VHA utilization (B = 0.98, SE = 0.16), whereas greater military social support was associated with better health (B = 0.97, SE = 0.44) and less frequent VHA utilization (B = -0.15, SE = 0.05). Neither moderation model was significant, such that military social support behaved in a similar way regardless of PTSD status.