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PubMed2000

Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans.

Despite numerous studies on veterans of the 1990 to 1991 Gulf War, the fundamental questions of how healthy they are and how their health compares with that of their military peers who were not deployed to the Gulf have not been fully answered. We conducted a health survey in which the health outcomes of a population-based sample of 15,000 Gulf veterans representing various military branches and unit components (regular, reserve, National Guard) were compared with those of 15,000 non-Gulf veterans who were randomly sampled to mirror the number in the same military strata in the Gulf veteran group. In comparison with their peers, Gulf veterans had a higher prevalence of functional impairment, health care utilization, symptoms, and medical conditions and a higher rate of low general health perceptions. A longitudinal follow-up of the health of these veterans will be needed to detect changes in health status and to detect diseases with a long latency period.

Adult↗
PubMed2005

Health-related quality of life, functional impairment, and healthcare utilization by veterans: veterans' quality of life study.

OBJECTIVES: To describe the health status of veterans receiving care in a veterans integrated service network (VISN). DESIGN: Cross-sectional survey with prospective follow-up. SETTING: Former Upper Midwest VISN 13 (now a part of VISN 23), a regional Veterans Affairs (VA) network comprising five inpatient facilities and associated outpatient clinics. PARTICIPANTS: All veterans in VISN 13 who had at least one inpatient or outpatient encounter between October 1, 1997, and March 31, 1998. MEASUREMENTS: Health-related quality of life (HRQOL) assessed using subscales and component summaries from the 36-item short form for veterans (SF36-V), functional status assessed according to limitations in activities of daily living (ADLs), healthcare utilization assessed according to outpatient visits and hospitalizations, and death. RESULTS: Of 70,334 eligible veterans, 40,508 responded and reported baseline HRQOL significantly lower than that of the general U.S. population for the physical (35.6, P<.001) and mental (46.4, P<.001) component summary scores (PCS and MCS, respectively) of the SF36-V. Many reported complete inability or some difficulty in completing ADLs such as getting in and out of a chair (35.1%) and walking (45.3%). More than 58% indicated some degree of difficulty with at least one of the ADLs. In multivariate analysis, PCS and MCS were significantly associated with subsequent use of inpatient and outpatient care and with mortality. CONCLUSION: The low quality of life and associated high rates of health services utilization in VA patients imply a need for innovative strategies to improve the HRQOL and functional status of this population.

Aged↗
PubMed1989

Cancer risk in male veterans utilizing the Veterans Administration medical system.

Age-specific incidence curves, cumulative rates, and relative risks were estimated for selected malignancies among male veterans utilizing the Veterans Administration (VA) medical system during 1970 to 1982. Relative risks for malignant tumors of the lung, bronchus, larynx, oral cavity, and esophagus in males using VA hospitals were approximately double the rates for men of the Surveillance, Epidemiology, and End Results (SEER) cancer registry, thereby supporting the existence of strong effects of chronic cigarette smoking and alcohol consumption on the development of neoplasms at these specific anatomic sites. Relative to the SEER male population, there were significant reductions in the cumulative rates of neoplasms of the colon (15%) and extrahepatic biliary tract (30%), no differences in the rates of cancer of the stomach, small intestine, or pancreas, and a 50% increase in the cumulative rate of liver cancer among the veterans. Rates of malignancies of the genitourinary tract were similar in the VA and SEER registries with the exception of cancer of the penis, for which the cumulative rate was 50% higher in the veterans. These results are consistent with an excess of specific risk exposures among male veterans using VA hospitals, viz., cigarette smoking, alcohol consumption, poor nutrition, and other factors related to low socioeconomic status. The ultimate utility of the VA tumor registry will depend upon its exploitation by epidemiologists to provide leads for etiologic research.

Adult↗
PubMed1997

Elderly veterans receiving care at a Veterans Affairs Medical Center while enrolled in Medicare-financed HMOs. Is the taxpayer paying twice?

Elderly veterans who visit our Veterans Affairs (VA) Medical Center primary care clinic often mention they are enrolled in HMOs. Approximately 20% of patients hospitalized at our facility report health insurance coverage. Of 1,000 hospitalizations during a 6-month period in which veterans reported insurance coverage, 337 involved elderly veterans. Of these 337 hospitalizations, 218 (65%) were for 174 veterans who stated they were enrolled in a Medicare-financed HMO. The VA's Medical Care Cost Recovery Program deemed only 46 (21%) of the hospitalizations billable and received reimbursement for 20 (9%). Thus, the VA is providing costly services already paid for by the Health Care Financing Administration under prepaid capitation contracts, and recovers minimal reimbursement from the HMOs.

Aged↗
PubMed2004

The National Registry of Veterans with Amyotrophic Lateral Sclerosis: Department of Veterans Affairs Cooperative Studies Program (CSP) #500a.

In response to concern about the development of ALS among veterans of the U.S. armed forces, particularly Gulf War veterans, the Department of Veterans Affairs established a national registry of veterans with ALS. This Registry will identify living veterans with ALS, track the progression of their disease, and serve as a vehicle to facilitate study of epidemiological risk factors for ALS in a military context. The Registry will also function as a means of communication with the enrolled patients about basic and clinical ALS-specific research. Executive and scientific research committees guide the activity of the registry.

Amyotrophic Lateral Sclerosis↗
PubMed2001

Health status assessments using the Veterans SF-12 and SF-36: methods for evaluating otucomes in the Veterans Health Administration.

This article describes a study in which the administration of two health surveys, the Veterans SF-36 and SF-12, by telephone and mail-out was used to assess the differences in the health surveys' costs and scores by mode of administration and determine which mode was cost-efficient. The study employed a crossover design: after 12 unsuccessful attempts to contact patients by telephone, the patients were administered the survey by mail, and after 2 unsuccessful mail-outs, up to three attempts were made to interview the patients by telephone. The analysis of the data showed that mail administration, with or without crossover to telephone, was more cost-efficient than telephone administration, having both lower average total and variable costs per completed questionnaire. Overall, telephone administration was about 30% more expensive that mail administration, primarily due to the cost of labor. The marginal cost of an additional completed Veterans SF-12 or Veterans SF-36 was also substantially lower for mail administration. Mail administration without crossover to telephone administration was the most cost-efficient strategy for administering both the Veterans SF-12 and SF-36. The results of this study strongly suggest the need to consider the mode of administration if questionnaires like the Veterans SF-12 or SF-36 are to be used to assess health outcomes within and across large health care systems.

Costs and Cost Analysis↗
PubMed1982

Why veterans choose Veterans Administration hospitalization: A multivariate model.

Data from a national survey of veterans are analyzed to determine how age, income, health insurance and service-connected disability influence the veteran's choice of Veterans Administration (VA) hospitalization. Log-linear analysis is used to provide a model that expresses in numerically quantifiable terms (odds and odds ratios) the effects of these factors on the choice of VA hospitalization. Moreover, the multivariate nature of the analysis provides the opportunity for assessing the magnitude of these effect simultaneously in the presence of all other effects. The final model shows that age and health insurance act independently of each other and of all other factors. The effect of income is modified by service-connected disability status and vice versa; this interaction of two factors is probably due to VA hospital care eligibility criteria. Overall, the single most important factor affecting a veteran's choice of hospitalization is health insurance; veterans without health insurance have nearly five times greater odds of going to VA hospitals than do those with health insurance-regardless of age, income or service-connected disability status.

Age Factors↗
PubMed1995

Resources needed to enhance and develop health services research to improve the oral health status of the aging veteran in the Department of Veterans Affairs System.

Health services research (HSR) in the Department of Veterans Affairs (VA) is one way in which to study the oral health care delivered to aging veterans and to ensure the most effective and efficient methods of meeting their oral health needs. This article details the current resources and infrastructure within VA dentistry that could be used to support a dental HSR agenda, followed by recommendations for improvements. The Department of Veterans Affairs' current situation regarding dental HSR is as follows: Dental health services research within VA needs expansion. Staff dentists have neither the training nor the incentives to conduct dental HSR. Dental clinic administrators are discouraged from being supportive of research due to the high clinical work-load requirements present at most dental services. Dental service affiliations with universities are not structured to support HSR. The HSR personnel outside of the dental services do not have the time nor the inclination to engage in dental HSR. Few recruitment and training initiatives are used to increase the number of VA dental health services researchers. Although funding sources exist that could be used to support dental HSR, the lack of trained and interested research personnel prevents full use. The Department of Veterans Affairs data collection in dentistry are inadequate to support dental HSR. If the required changes occur, VA is uniquely situated to be the largest contributor to dental HSR in the United States and to act as a catalyst for improving dental HSR throughout the nation. Recommendations for improvement of VA dental HSR are as follows: Restructure the Dental Activity System to include detailed diagnostic and treatment data as part of an integrated computerized patient record. Develop and implement a strategic plan with a detailed timeline for increasing dental HSR in VA. Recruit staff dentists with formal research training and provide them protected research time and resources to conduct meaningful research. Develop academic affiliations with centers of excellence in dental HSR. Develop full-time equivalent employee positions dedicated to research at the proposed Veterans Service Areas level. Develop incentives to increase collaboration with non-VA health services researchers in addressing VA issues. Develop dental HSR training programs modeled after the Career Development Program, Dental-Geriatric Fellowship, and Dentist-Scientist Programs that will permit VA to become a leader in dental HSR training. Develop mechanisms to ensure adequate and sustained funding for dental HSR projects. Ensure that dissemination techniques are effective and result in improvements in operational effectiveness and quality of care.

Aged↗
PubMed2006

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.

Data Collection↗
PubMed2005

Health-related quality of life predicts future health care utilization and mortality in veterans with self-reported physician-diagnosed arthritis: the veterans arthritis quality of life study.

OBJECTIVE: To investigate whether health-related quality of life (HRQOL) measures predict health care utilization and mortality in a cohort of veterans with self-reported physician-diagnosed arthritis. METHODS: A cohort of veterans from the Upper Midwest Veterans Integrated Service Network (VISN) was mailed a self-administered questionnaire that was composed of the SF-36V (modified from SF-36 for use in veterans) and questions regarding demographics, current smoking status, limitation of activities of daily living (ADLs), and preexisting physician-diagnosed medical conditions, including arthritis. Within subjects reporting physician-diagnosed arthritis, we analyzed the associations between the SF-36V component summary scales (physical and mental component summary, PCS and MCS, respectively) and the occurrence of any hospitalization, number of hospitalizations, number of outpatient visits, and mortality, for the year after survey administration, using multivariable regression analyses. RESULTS: Of 34,440 survey responders who answered a question regarding arthritis, 18,464 (58%) subjects reported physician-diagnosed arthritis. Arthritic patients in the lowest tertile of PCS scores had significantly higher odds of any hospitalization (Odds ratio (OR) 1.49, 95% confidence interval (CI) [1.25-1.76]) and mortality (OR 1.69, 95% CI [1.18-2.42]), and a significantly higher number of hospitalizations/year (Rate ratio (RR) 1.09, 95% CI [1.05-1.13]) and outpatient visits/year (RR 1.07, 95% CI [1.03-1.11]). Arthritic patients in the lowest tertile of MCS scores had significantly higher odds of any hospitalization (OR 1.20, 95% CI [1.02-1.41]), mortality (OR 2.14, 95% CI [1.56-2.94]), and a significantly higher number of hospitalizations/year (RR 1.05, 95% CI [1.02-1.09]) and outpatient visits/year (RR 1.07, 95% CI [1.03-1.11]). CONCLUSIONS: HRQOL, as assessed by the SF-36V, predicts future inpatient and outpatient health care utilization and mortality in veterans with self-report of physician-diagnosed arthritis.

Activities of Daily Living↗
PubMed2001

A multicenter two by two factorial trial of cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: design of a veterans affairs cooperative study (CSP #470).

The Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) Study #470 is a 2 x 2 factorial trial designed to evaluate the hypothesis that both cognitive behavioral therapy (CBT) and aerobic exercise will significantly improve physical function in participants with Gulf War veterans' illnesses (GWVI), and that adding CBT to aerobic exercise will provide further incremental benefit. One thousand three hundred fifty-six veterans will be randomized to one of four treatment arms: CBT plus aerobic exercise plus usual and customary care, aerobic exercise plus usual and customary care, CBT plus usual and customary care, or usual and customary care alone. The study duration is 2.5 years with 1.5 years of intake and 1 year of follow-up. The primary outcome measure is the proportion of veterans improved more than seven units on the physical component summary (PCS) scale of the Short Form Health Survey for Veterans (SF-36V) measured 12 months after randomization. This generic quality-of-life measure was chosen because there is no disease-specific measure for GWVI and the symptoms of GWVI span a wide range of physical manifestations that are related to the domains covered by the PCS scale. Sample size was determined to detect all six pairwise comparisons between the four treatment arms with 90% power and a Bonferroni adjustment for an overall type I error of 0.05 or 0.05/6 = 0.0083. CSP #470 was initiated in May 1999 in 18 VA and two Department of Defense medical centers. To date this represents the largest randomized trial designed to evaluate treatments for individuals with unexplained physical symptoms. This paper will focus on the rationale and unique features of the study design. Control Clin Trials 2001;22:310-332

Cognitive Behavioral Therapy↗
PubMed1995

Ascertainment of mortality in the U.S. veteran population: World War II veteran twins.

Veterans now make up nearly two-thirds of U.S. males aged 65 and older, and thus medical research in the male geriatric population is largely concerned with veterans, whose mortality experience assumes greater importance as they age. Department of Veterans Affairs (VA) records provide an effective and efficient means of gathering information on mortality of veterans, but are useful only if they provide relatively complete ascertainment. We investigated the completeness of VA death reporting (via the Beneficiary Identification and Records Locator Subsystem [BIRLS]) in a large cohort of nearly 32,000 World War II veteran twins followed from 1946 through 1990, comparing VA and Social Security Administration (SSA) mortality ascertainment. The small number of additional deaths found using SSA records--roughly 3% of total deaths--provides evidence that VA death reporting was nearly complete. A further capture-recapture analysis, assuming independence of BIRLS and SSA mortality ascertainment, indicated that BIRLS ascertainment was 95.4% complete.

Aged↗
PubMed1999

Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study.

OBJECTIVE: The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans. METHOD: Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews. RESULTS: The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders. CONCLUSIONS: Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.

Alcoholism↗
PubMed2006

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.

Black or African American↗
PubMed2006

Symptom patterns associated with chronic PTSD in male veterans: new findings from the National Vietnam Veterans Readjustment Study.

A subsample of 255 male Vietnam veterans from the National Vietnam Veterans Readjustment Study received in-depth psychiatric diagnostic interviews. This paper focuses on the 88 veterans with a war-related onset of PTSD. Among these veterans, the avoidance cluster, especially its symptoms of numbing, was most strongly associated with chronic PTSD; less strongly but also significantly associated was the hyperarousal cluster. Further analyses show that these associations are not artifacts of the relationship of symptom patterns to prewar demographic factors (race/ethnicity, socioeconomic status, age at entry into Vietnam), comorbidity, treatment and compensation seeking, or probable severity of war-related trauma. We conclude that certain symptom profiles may predict enduring pathological responses to trauma and therefore provide targets for intervention efforts.

Chronic Disease↗
PubMed1982

An inpatient program for Vietnam combat veterans in a Veterans Administration hospital.

The Veterans Administration's first inpatient program for Vietnam War veterans was opened in January 1978 at the VA Medical Center in Palo Alto, California. The unit treats a range of psychiatric disorders; however, the typical patient is a 34-year-old white male with a diagnosis of posttraumatic stress disorder and at least one previous hospitalization. The program is designed as a three-phase therapeutic community based on mutual support and group solidarity. Medication is minimized. The program also reflects the assumptions that a debriefing, however belated, from military experience is essential, and that the clinical regimen should enable veterans to resume the transition to adulthood that the war interrupted. The average stay is five months; preliminary evaluation indicates that 60 per cent of the veterans achieve relief from acute psychological distress, resolve a crisis with a spouse or significant other, and begin a job or schooling.

California↗
PubMed1980

Veterans Administration--Veterans' benefits; institutional awards. Final regulation.

The Veterans Administration has amended one of its regulations to increase the amount of monthly compensation, pension or retired pay payable to a chief officer of a non-VA institution on behalf of an incompetent veteran patient from $50 to $60. The need for this action results from enactment of the Veterans' and Survivors' Pension Improvement Act of 1978 which increased the amount of benefits payable to hospitalized veterans without dependents from $50 to $60.

Economics, Hospital↗
PubMed2003

Healthcare use by veterans treated for diabetes mellitus in the Veterans Affairs medical care system.

OBJECTIVES: To estimate the burden of comorbid conditions and to describe patterns of inpatient and outpatient service use by veterans with diabetes mellitus. STUDY DESIGN: Retrospective cohort study of 33,481 veterans conducted by means of secondary analysis of Department of Veterans Affairs (VA) healthcare utilization databases. PATIENTS AND METHODS: The cohort was constructed by enrolling all veterans treated in the VA medical care system who had their initial VA hospitalization for diabetes mellitus between 1992 and 1997. To estimate the typical annual pattern of service use for diabetes mellitus, 1997 utilization rates per person-year were analyzed based on cohort members surviving into 1997. Data on comorbid conditions were obtained from outpatient and inpatient contacts. RESULTS: The 3 most prevalent coexisting conditions were hypertension (73.4%), ischemic heart disease (35.2%), and alcohol or drug abuse disorders (29.5%). In 1997, the typical cohort member followed for 12 months had 6 primary care visits, 16 other visits for tests or consultations, and 1.3 unscheduled visits for emergency or urgent care and spent approximately 8 days in the hospital. One-year survival was 94.0%. CONCLUSIONS: In the VA medical care system, beneficiaries with diabetes mellitus have an extremely heavy burden of comorbidities, face a significant risk of dying in a given year (approximately 6% in this population), and are heavy users of hospital and outpatient services.

Adult↗