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Bean-Mayberry B, Huang C, Batuman F, et al. Systematic Review of Women Veterans Health Research 2004–2008 [Internet]. Washington (DC): Department of Veterans Affairs (US); 2010 Oct.

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Systematic Review of Women Veterans Health Research 2004–2008 [Internet].

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APPENDIX 8ACCESS AND UTILIZATION EVIDENCE TABLE

AuthorSample CharacteristicsSample SizeDesign/ObjectiveMain MeasuresMain Findings
Bean-Mayberry 2008100Random sample of female veterans in 10 regional VAMCs, with an outpatient visit in primary care or women’s clinic between 3/1/1999 – 3/1/2000Females
1051
Observational;
To compare female veterans who use the VA for primary care with female veterans who use both VA and non- VA providers (dual use) and identify the health care factors associated with dual use
Dual use of VA and non-VA providersHaving a VA provider perform general gynecologic care (OR 0.37, 95%CI 0.22, 0.60) and use of a VA women’s clinic (OR 0.56, 95%CI 0.35, 0.90) were each associated with significantly lower odds of dual use.
Dissatisfaction with overall VA care (OR 1.88, 95%CI 1.04, 3.41) and higher income (OR 1.89, 95%CI 1.32, 2.71) were significantly associated with higher odds of dual use.
Female provider had no effect on dual use (OR 0.87, 95%CI 0.53, 1.40).
Borrero 2006117Female and male VA patients in fiscal year 1999, age 50 years or older with or without the diagnosis of osteoarthritis (OA) in any joint were included.Females
44569
Males
1,923,524
Observational;
To examine gender differences in the utilization rates of total knee/hip arthroplasty in the Veterans Administration (VA) system.
Primary outcome was undergoing knee or hip total joint arthroplasty within 2 years (fiscal years 2000 and 2001).Of the total 1,968,093 (2.3% women) VA patients in FY 1999 who were 50 years of age or older, 329,461 (2.9% women) patients carried a diagnosis of OA. For women, the 2-year adjusted odds of undergoing total knee or hip arthroplasty was 0.97 (95%CI 0.83 to 1.14) and 1.00 (95%CI 0.79 to 1.27), respectively yielding no statistically significant gender differences within the study period.
Carney 2003141Female and male population based sample in the Iowa Gulf War Study who were on active duty/activated and deployed in the Persian Gulf War between August 1990 and July 1991.Females
129
Males
1767
Observational;
To provide a descriptive study of women and men who were deployed to the region of the Gulf War in order to compare their combat experiences, occupational exposures, and self reported use of health care services 5 years after deployment.
Environmental and combat exposures, health care utilizationNo significant deployment differences were seen by gender; lengths of stay, locations deployed, and primary occupation groups were similar by gender. Similar overall mean numbers of combat and noncombat exposures were experienced by women and men(10±0.4 vs. 10±0.1). Men reported a higher level of preparedness for combat and more frequently participated in combat. Compared to men, women were more likely to have more than 5 outpatient visits during the previous year, have an inpatient hospitalization, and receive VA compensation.
Chen 2007120National sample of homeless veterans who had an outreach intake and first contact with the Health Care for Homeless Veterans (HCHV) program at any of the VAMC sitesFemales
188
Males
5543
Observational;
To identify factors associated with receipt of VA pension and compensation benefits among homeless veterans after their initial contact with the VA national home-less (community) outreach program.
Proportion of homeless veterans who were awarded any benefits; sociodemographic, clinical, and military service characteristics of beneficiaries and nonbeneficiaries in the program and those who receive pension benefits or compensation benefitsFemale veterans were more likely to receive compensation benefits than pension benefits. Homeless female veterans might be less likely than male veterans to be referred to VA mental health services by non-VA clinicians because clinicians might not ask whether the women were veterans. A limited number of veterans (15%) were subsequently awarded benefits; they were more likely to have reported recent use of VA services and a greater number of medical and psychiatric problems at the time of outreach.
Dobie 2006129Female veterans receiving care between 10/01/1996 – 1/01/2000 at VA Puget Sound Health Care SystemFemales
2578
Observational;
To determine associations between medical/surgical utilization and PTSD in female patients
Rates of medical/surgical hospitalizations, surgical inpatient procedures, and outpatient utilization for PTSD positive and PTSD negative women.Female veterans who screen positive for PTSD receive more VA medical/surgical services. About 33% of the women screened positive for PTSD. PTSD+ women had higher rates of medical/surgical hospitalizations of 20% vs. 14% overall. In particular, PTSD+ women ages 35–49 had significantly more mean hospital days compared to PTSD− women (43 vs. 17 days, p<.0001). Similarly, more PTSD+ women ages 35–49 underwent surgical procedures (5.9% vs. 1.7%, p<.001). Mean annual outpatient visits were also significantly higher among PTSD+ women (p<.001 for each comparison).
Erbes 200715Female and male OEF/OIF veteran enrollees at one Midwestern VAMC who had returned within a six-month time frameFemales
17
Males
103
Observational;
To evaluate levels of PTSD, depression, alcohol abuse, quality of life, and mental health service utilization among returnees from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
psychiatric distress levels (PTSD symptoms using PCL, depression using Beck Depression scale, and alcohol use using AUDIT), functional impairment, and service utilizationPTSD levels (12%) were consistent with previous research while problematic drinking levels were also elevated (33%). PTSD and, to a lesser degree, alcohol abuse were associated with lower quality of life in multiple domains, even when controlling for the influence of depression. Of those screening positive for PTSD, 56% reported using mental health services. Only 18% of those screening positive for alcohol abuse reported using such services. No reported findings related to gender.
Fontana 2006135Female veterans with consecutive admissions to the Women’s Stress Disorder Treatment Team (WSDTT) at 4 VA sites.Females
224
Observational;
To examine the role of women’s comfort in coming for treatment of PTSD in a predominantly male environment
Female veterans comfort level when entering treatment and while participating in therapy, socio-demographic and clinical characteristics associated with comfort level, and strength of association of comfort level and participation and satisfaction with treatment.(1) As a group, women treated for military-related stress disorder were “somewhat comfortable” in coming to the VA for specialized PTSD treatment from the start. The most important factor contributing to their level of comfort was the availability of a specialized treatment program for women. (2) Women who had prior contact with the VA reported no change in comfort level over the 8-month period. Women who did not have prior contact with the VA reported an increase in comfort from intake to 4 months. (3) Among women who did not have prior contact with the VA, those of minority ethnicity had significantly lower comfort levels, and, among women who did have prior contact with the VA, those with higher levels of education had significantly lower comfort levels. (4) Among women, comfort level did not have a significant effect on their satisfaction with treatment.
Frayne 2008112National sample of all female and male (veteran and non-veterans) in FY2002 VA enrollee databaseFemale veterans
178,849
Male veterans
3,943,532
Female Non-vets
183,722;
Male Non-vets
123,311
Observational;
To determine whether gender differences in VA utilization and cost change when comparing all VA users versus the veteran only cohort.
Total # outpatient encounters in FY 2002; primary care visits in FY 2002; inpatient length of stay; cost of outpatient care and inpatient care-Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men.
-Among all VA users, women were younger and less likely to have a medical or mental health condition.
-However, veteran women were more likely to have a mental health condition than veteran men, and more likely to have 3 or more primary care visits during the year. Women veterans had a higher mean # of visits compared to men veterans and a higher cost for outpatient care (p<.001). Women veterans also had lower inpatient utilization and cost (p<.001).
Frayne 2006111Female and male veterans in VA administrative databases in FY 2002 (outpatient, inpatient, pharmacy); non-veterans are excludedFemale veterans
178849;
Male veterans
3,943,532;
Observational;
To examine how utilization and cost of VHA care differ between female and male veterans
Number of inpatient days and outpatient encounters; costs of inpatient, outpatient and pharmacy care-Women had 10.9% fewer inpatient encounters, 1.3% more outpatient encounters, and significantly lower total costs (−2.8%) and lower inpatient costs (−20.8%) compared to men (p<.001 for each comparison).
-Women veterans utilized more outpatient services if they had both medical and mental health conditions compared to men.
-Women veterans were significantly younger, unmarried, more often service connected, and more often had mental health diagnoses.
Frueh 2007131Random sample of female and male veterans less than 80 years old at 4 VAMC primary care clinics selected in fiscal year 1999Females
50
Males
695
Observational;
To expand our understanding of PTSD prevalence, its psychiatric characteristics, and service use among elderly veterans in VA primary care clinics
prevalence of PTSD and psychiatric diagnoses by age; physical and mental health functioning by age; use of VA mental health services and disability benefits; identification of explanatory characteristicsThose in the 45–64 year age group endorsed the highest scores and those in the oldest age group (65 and older) endorsed the lowest scores, even after adjusting for the effects of race and sex. Similarly, those in the oldest group (7.5%) had one-third of the prevalence of major depression as those in the two younger groups (21.7% and 22.9%), and they had a lower prevalence of other psychiatric conditions, such as panic disorder, agoraphobia, social anxiety, and substance abuse. They also were about half as likely to show evidence of suicidal risk. In all cases, these differences were maintained even after controlling for relevant demographic covariates, such as race and sex. Those in the 45–64 year old group were generally more likely to meet criteria for most psychiatric disorders, followed by the 18–44 group, and then the 65 and older group. All but one of these relationships remained significant after adjusting for the effects of race and sex. The one exception was in rates of substance abuse/dependence between the 45–64 and 65 and older groups.
Greenberg 2004137Female veterans entering outpatient treatment for PTSD at one of 4 VA Women’s Stress Disorders Treatment Programs (Boston, Brecksville, Loma Linda, New Orleans).Females
149
Observational;
To examine the strength of association between continuity of care and health outcomes for female veterans newly entering outpatient treatment for PTSD.
Changes in clinical status between program entry and four months follow-up on 11 measures (e.g., PTSD symptoms, general psychiatric/physical health, alcohol and drug abuse, violent behavior).1) Few significant associations between continuity and outcomes were found.
2) Four months after program entry, only commitment to treatment (treatment process) was positively associated with one or more continuity of care measures.
3) Severity continuity of care measures were associated with poor health outcomes.
4) Eight months after program entry, patients with greater continuity of care during the first four months of treatment had greater declines in violent behavior and PTSD measurements and larger increases in global functioning.
5) However, corrections for multiple comparison resulted in no statistically significant relationships, demonstrating only weak and inconsistent evidence of the clinical benefits of continuity of care for women entering care for PTSD.
Grubaugh 2006130Randomly identified female veterans who attended primary care clinic in any of the four VA sites in fiscal year 1999 (Charleston and Columbia, SC; Tuscaloosa and Birmingham, AL)Females
187
Observational;
To examine rates of medical and psychiatric disorders among female veterans, the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA setting
Frequency of psychiatric diagnoses, diagnostic accuracy, and medical comorbidity; Frequency of medical disorders and medical and psychiatric comorbidity; Functioning (SF-36 mental & physical health composite scores); Use of VA Health Services by psychiatric diagnosis; Use of outside careForty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year.
Haskell 200881National Sample of women VA users identified through pharmacy benefits data in 2001 as receiving a prescription for oral conjugated equine estrogen, estradiol, the estradiol patch or any estrogen preparation in combination with medroxyprogesterone as hormone therapy (HT)Females
36,222
Observational;
To (1) determine whether the decline in HT use nationally also occurred among female veterans taking HT in 2001, occurred after 2002 during 2003 and 2004, and (2) deter- mine whether treatment in a specialized women’s health clinic versus other clinic settings affected HT discontinuation rates.
Any HT use within the specified calendar year, regardless of duration of use, discontinuation was defined as no longer having any use in the specified year.In 2001, 36,222 female veterans used HT. By 2004, 23,924 (66%) had discontinued HT. Subjects who used a VA women’s clinic or were younger (40–54 years of age) were significantly less likely to discontinue HT. However, His- panic ethnicity, African American race, and clinical diagnoses such as heart disease and mastectomy were significantly associated with discontinuation. Discontinuation rates in the VA parallel those in the private sector. However, patients with any use of VA women’s clinics were less likely to discontinue HT, indicating a practice setting variation that may indicate either more specific care or differential implementation of the new HT guidelines.
Haskell 2006121Convenience sample of women veterans receiving care in the VA Connecticut Women’s Health CenterFemales
213
Observational;
To provide descriptive data about pain among women veterans receiving care in a VA primary care setting
Prevalence of pain and key pain dimensions in a sample of women veterans(1) Most women veterans (78%) reported an ongoing pain problem with a mean duration of 6 years, average pain intensity of 6.3 (range 1–10), and most commonly endorsed pain sites included lower extremity (68%), low back (63%), and shoulder (48%). (2) Women older than 65 years reported lower use of pain treatments. (3) Those with pain (vs. without) were more than 6 times as likely to report ≥12 medical visits in the past year and twice as likely to report ≥12 visits to a mental health provider.
Hatmaker 2006116Female patients who presented to VA General Surgery Clinic at one site with a breast mass or abnormal mammogram from 2003 to 2005.Females 62Observational;
To examine the costs and trends in the use of surgical versus percutaneous image-guided biopsy procedures.
Number and type of procedures each year, location of procedure (VA or non-VA hospital) and total costs associated with open or percutaneous biopsies were calculated.(1) The average total cost to evaluate a patient with a breast mass or mammographic abnormality through an open biopsy in the operating room at the VA hospital was $4,368 (SD, $2,586) with a median cost of $3,479. (2) The average total cost for a percutaneous image- guided breast biopsy was $1,267 (SD, $536) with a median cost of $1,239. (3) A 3.8-fold increase in the use of percutaneous image-guided techniques for the evaluation of breast lesions over a recent 3-year period was observed. (4) For VA with available resources, the option of image-guided percutaneous biopsy techniques is a cost-effective and more preferable alternative to open surgical biopsy.
Hoge 200620Female and male Army soldiers and marines who completed a Post-Deployment Health Assessment (PDHA) between May 1, 2003, and April 30, 2004, on return from deployments to OEF, OIF, and other locations (e.g., Bosnia, Kosovo)Females
32,500
Males
271,404
Observational;
To determine the relationship between deployment to Iraq and Afghanistan and mental health care utilization during the first year after return and to evaluate lessons learned from the postemployment mental health screening effort, particularly the correlation between screening results and actual use of mental health services.
Screening positive for PTSD, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; attrition from military services(1) The prevalence rates of mental health problems and combat experiences were consistently higher following deployment to OIF than to OEF or other locations. Among OIF veterans, 23.6% of women reported a mental health concern compared with 18.6% of men. (2) Referral to mental health was strongly correlated with screening positive for a mental health problem on the PDHA. Hospitalization was significantly associated with deployment location and reporting a mental health concern on the PDHA. (3) OIF veterans used impatient and outpatient mental health services at higher rates after deployment than OEF veterans and service members who deployed to other locations.
Hynes 2007109National sample of veterans who were eligible to use VA and Medicare health care in calendar year 1999.Females
37817
Males
1,436,600
Observational;
To examine the impact of access to care characteristics on health care use patterns among those veterans dually eligible for Medicare and Veterans Affairs (VA) services.
Availability of health care resources, healthcare utilization; and cost; other factors included patient characteristics (age, gender, race, vital status), VA priority level, patient health status, distance to nearest VA facility, and demo-graphic setting.Multivariable analysis revealed that veterans who were black or had a higher VA priority were most likely to rely on the VA. Patient with higher risk scores were most likely to rely on a combination of VA and Medicare health care. Patients who lived farther from VA hospitals were less likely to rely on VA health care, particularly for inpatient care. Patients living in urban areas with more health care resources were less likely to rely on VA health care. Male veterans were less likely to rely exclusively on VA care than female veterans and less likely overall to rely on some VA care.
Kaplowitz 2006134Female and male veterans at least 20 years old who had used outpatient services in the VA New England Health Care System at least once between January 1998 and December 1999 and at least once between January 2000 and June 2001Females
2744
Males
61,746
Observational;
To examine the relationship between mental illness, health care utilization and rates of cholesterol testing
receipt of cholesterol testing; mental illness diagnosis; frequency of VA outpatient visitsAmong veterans using VA outpatient services infrequently, those with mental illness were less likely than non-mentally ill control subjects to receive a cholesterol test during the study period (first quartile adjusted OR [aOR]=0.45, 95% CI 0.37–0.54; second quartile aOR=0.50, 95% CI 0.45 0.57). Mentally ill subjects with more frequent utilization of VA services were as likely as (third quartile aOR=1.01, 95% CI 0.91–1.13) or more likely than (fourth quartile aOR=2.73, 95% CI=2.46– 3.03) non-mentally ill subjects to receive cholesterol testing. Mental illness was associated with a lower likelihood of cholesterol testing in subjects who used fewer VA outpatient services. The observed disparity attenuated at higher levels of service utilization.
Kaur 2007115Female and male veterans at the Durham Veterans Affairs Medical Center between the ages of 21 and 60 that had two visits for the same pain location at least 6 weeks apart.Females 406
Males
812
Observational;
To identify differences in outpatient utilization between men and women veterans with chronic pain.
Visit data, number of pain sites, number of chronic pain conditions, comorbidity scores, and mental health diagnosis (depression, PTSD, substance abuse).After adjusting for multiple pain sites, psychiatric diagnoses, age, and comorbidities, women veterans had a 27% higher rate of outpatient visits than men. Specifically, women had higher rates of visits to primary care, physical therapy, and other clinics, and had a higher rate of visits to address pain than did men. Women veterans with chronic pain may need more resources to adequately manage chronic pain conditions as well as associated comorbidities and psychiatric disease.
Kelly 2008125National, cross-sectional sample of female veterans from the National Registry of Women Veterans stratified by age group, period of service, and race (black and non- black)Females
1496
Observational;
To investigate the effects of military sexual assault and combat exposure on women veterans’ use of Veterans Health Administration (VHA) services and perceptions of VHA care.
Military sexual assault history, combat exposure, use of VHA services, satisfaction with VHA servicesWomen veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure.
Kimerling 2008123Female and male veteran patients with valid positive or negative responses to military sexual trauma screening and at least one outpatient encounter 180 days before or after the screening date as identified by the VA Outpatient Events FileFemales
33,259
Males
540,381
Observational;
To evaluate the national efforts to screen for and treat military sexual trauma by prospectively examining rates of mental health utilization in 3-month period after screening.
Outpatient mental health services included specialized mental health or substance abuse treatment clinics; prescreen mental health care was 1 or more mental health visits in 6-months before the screening; postscreen mental health treatment was defined as 1 or more mental health visits in 3-months after screening.Rates of positive screens were 19.5% for women and 1.2% for men. For both women and men, a positive military sexual trauma screen was associated with over twice the likelihood of postscreen mental health care, compared with negative screens. The number needed to screen to provide an impact number associated with the screening was one for every 5.5 positive screens in women and one for every 7.2 positive screens in men.
Lairson 2005119National random sample of female veterans 50 years or older taken from the National Registry of Women VeteransFemales
3415
Observational;
To identify and measure the effect of economic, demographic, and behavioral factors that influence the use of mammography screening among US women veterans aged 50 and older
Mammography screening in the past year (15 month period used)The findings included: about 75% of the women veteran respondents received a screening mammogram within the interval; and the demand models achieved a correct prediction for 75–77% of the sample. In the first model, increasing age, poor health, and smoking were inversely related to mammography use. In the second model, age, health status and income had smaller effects, and prior waiting time was inversely related to mammography screening in the past year.
Lang 2006133Female veterans who received medical care from San Diego VA Healthcare SystemFemales
221
Observational;
To examine whether current post-traumatic stress disorder (PTSD) mediates the relationship between exposure to childhood maltreatment (CM) and indicators of health and healthcare utilization in female veterans
Relationship between PTSD, exposure to childhood maltreatment (CM) and indicators of health and healthcare utilizationIncreased emotional abuse (β = −.32, p = .02) was associated with poorer functioning on the SF-36 role-physical scale; increased emotional neglect (β = .27, p = .02) was associated with better functioning on the same scale. Higher levels of emotional abuse (β = −.32, p = .01) were associated with increased SF-36 bodily pain and greater odds of using pain medication in the past 6 months (OR = 1.14, p = .01). Greater physical abuse scores was associated with poorer SF-36 general health (β = −.24, p = .04), and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and
LaVela 2004122Cross-sectional sample of veterans with SCI&D diagnoses identified from the Spinal Cord Dysfunction Registry (SCD-R) for 2001Females
180
Males
8803
Observational;
To describe inpatient (IP) and outpatient (OP) health care utilization of veterans with spinal cord injuries and disorders (SCI&D); to determine whether the health care utilization patterns of patients who reside at greater distances from their actual sources of care differ from those at shorter distances; to examine overall health care usage at the facility level to identify the types of VA facilities being used by SCI&D patients;
Inpatient and outpatient utilization-Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000).
-Female, older, and non-white veterans (p<.0.000 each), and veterans with a history of respiratory, kidney/urinary tract, circulatory, or digestive system diseases (p<0.005 for each) were more likely to use outpatient care during the study period.
-History of prior illnesses, including respiratory, kidney/urinary tract, circulatory, digestive system, or skin/subcutaneous tissue or/breast-related illnesses (p<0.000 for each) were associated with greater likelihood of inpatient use.
LaVela 2006113Female veteran data from a national cross-sectional survey mailed to Paralyzed Veterans of America (PVA) members for the SCI&D group and data from the CDC 2003 Behavioral Risk Factor Surveillance System (BRFSS) survey for the non-SCI&D comparison groupFemales
593
Observational;
To compare disease prevalence and preventive service use among female veterans in general and those with spinal cord injuries and disorders (SCI&D)
Disease/condition prevalence (asthma, diabetes, myocardial infarction, stroke, coronary heart disease, high blood pressure, high cholesterol, tooth decay/gum disease, injuries), health status (general health, physical and mental health), and use of preventive services (cholesterol check, dental care, influenza and pneumonia vaccinations, colon screening, breast and cervical cancer screening) among women veterans with and without SCI&DFemale veterans with SCI&D were similar in age and race but were better educated and less likely to be employed than female veterans in general. Coronary heart disease (CHD) prevalence was higher in those with SCI&D (17% vs. 8%, p < 0.0001). Health status was lower in SCI&D (27%) than in general female veterans (41%), p = 0.002. Fewer women with SCI&D, than female veterans in general reported having received recommended dental care (56% vs. 69%, p=0.004), colon screening in prior 5 years (59% vs. 72%, p = 0.023) or prior 10 years (67% vs. 92%, p < 0.0001), mammogram (84% vs. 91%, p = 0.019), and Pap smear (88% vs. 98%, p < 0.0001). There were no differences in receipt of respiratory vaccinations or cholesterol screening.
Maguen 2007139Female and male Vietnam veterans who served in the Vietnam theater of operations sometime between August 1964 and March 1975, who also participated in the National Vietnam Veterans Readjustment Study.Females
432
Males
1200
Observational;
To examine both direct and mediated relationships using predisposing factors, enabling factors, and need factors to predict medical and mental health care use for male and female veterans.
Predisposing variables (age, race, marital status, and combat exposure; enabling variables (family income, access to insurance); need variables (total number of psychiatric diagnoses, average number of physical health conditions, PTSD severity); service utilization variables (mental health care service utilization, physical health inpatient care utilization, physical health outpatient care utilization).Need factors were the most consistent and strongest mediators of predisposing variables for both physical and mental health care service utilization, although there were differences between male and female veterans. For men, combat exposure indirectly predicted mental health care utilization through the need variables (with the effects of posttraumatic stress disorder being greatest). For women, physical health problems mediated the relationship between combat exposure and physical health outpatient care utilization.
McNulty 200525Female and male active duty Navy service members deployed on three aircraft carriers during OEF/OIF in 2002–2003Females
259
Males
923
Observational;
To describe the health care needs and perceived stressors of active duty members deployed to Iraq during the predeployment, mid-deployment, and postdeployment phases.
Member well-being, adaptation, coping, anxiety, stress, and health care needsLogistic regression analyses indicated that many variables predicted extreme anxiety during deployment, including middeployment phase, age of under 25 years, being childless, nonattendance at church, being enlisted, zero-or one-deployment history; no high school education, and being currently in counseling. Active duty members in all phases of deployment had equally disturbing levels of anxiety. All phases reported suicidal ideation at alarming rates (2.4% in predeployment, 4.9% in mid-deployment, and 3% in postdeployment).
Miller 2006132National sample of female and male VA users during FY 2000 with no evidence of nursing home treatment during FY 1999 or FY 2000, followed through FY 2003 using administrative claims data.Females
17096
Males
206,760
Observational;
To determine whether patients with mental health diagnoses in the Department of Veterans Affairs (VA) are more likely to be admitted to nursing homes and to identify sociodemographic, utilization, and clinical characteristics associated with nursing home admission
Relationship between number of diagnosed mental illnesses and the risk of being admitted to a nursing homeAmong mentally ill patients, risk of admission was highest for those with any inpatient medical/surgical days (odds ratio [OR] 2.28, 95% confidence interval [CI] 2.13–2.43), followed by 3+ outpatient medical visits (OR 1.48, 95% CI 1.42–1.55), inpatient mental health days (OR 1.31, 95% CI 1.22–1.40), and outpatient mental health visits (OR 1.09, 95% CI 1.02–1.18). Patients diagnosed with dementia were 58% more likely to be admitted. Patients admitted to nursing homes were more likely to be older (P < 0.0001), men (P < 0.0001), white (P < 0.0001), single (P < 0.0001), had higher incomes (P < 0.0001), and suffered from greater service-related disability (P < 0.0001).
Mojtabi 2003138Female and male sample from National Collaborative Study of Early Psychosis and Suicide and comprised of U.S. Armed Forces personnel who had their first admission for major depression, bipolar disorder, or schizophrenia to a DoD hospital and were subsequently discharged from military services.Females
754
Males
2106
Observational;
To examine the use of Department of Veterans Affairs (VA) aftercare services among patients with serious mental disorders who were discharged from the military after a first admission to the Department of Defense (DoD) hospital.
Predictors of contact with VA versus no contact, and time to contact for those that do contact services.Fifty-two percent of 2,861 identified individuals had received outpatient care from VA mental health clinics by the end of September 1998. Women, older persons, and persons with schizophrenia or bipolar disorder were more likely to contact VA outpatient mental health services than men, younger persons, and those with major depression. Also, being female, older than 25 years at military separation and having a diagnosis of bipolar disorder or schizophrenia were predictors of contacting services: women were more likely than men to use services.
Mooney 2007108Female veterans enrolled in the VA system who had an inpatient admission between 1998 and 2000 in either the VA or the private sectorFemales
1409
Observational;
To explore women veterans’ use of Veterans Administration (VA) and private sector inpatient services
VA and private sector hospital admissions, length of stay (LOS), and method of payment for private sector careWomen admitted to the VA were less likely to be 65 or older (34% vs. 51%; p < .001); of those older women, those admitted to the VA were less likely to be enrolled in Medicare (87% vs. 96%, p <.001). Patients were less likely to be admitted to the VA for issues related to the female reproductive system (adjusted OR, 0.58; 95% CI, 0.39–0.87), the nervous system (adjusted OR, 0.64; 95% CI, 0.41–0.99), the musculoskeletal system (adjusted OR, 0.72; 95% CI, 0.52–1.02), or the digestive system (adjusted OR, 0.77; 95% CI, 0.52–1.14). In contrast, patients were more likely to be admitted to the VA for alcohol or drug use (adjusted OR, 2.79; 95% CI, 1.57–4.95), mental diseases (adjusted OR, 2.1; 95% CI, 1.46–2.89), or care related to the skin/subcutaneous tissue and breasts (adjusted OR, 1.7; 95% CI, 0.99–2.92). Mean observed LOS were longer in the VA system for every diagnosis examined (but only reached statistical significance for mental, musculoskeletal, and nervous system disorders) despite comparable or even lower levels of acuity.
Nelson 2007107National sample of veterans from the 2000 Behavioral Risk Factor Surveillance SystemFemales
1309
Males
22,488
Observational;
To examine veteran reliance on health services provided by the VA and to describe the characteristics of veterans who receive VA care and report rates of uninsurance among veterans and characteristics of uninsured veterans.
use of VA health care, socio-demographic characteristics, access to care, health status, and health insurance coverageAmong veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who used the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the year preceding the study.
Polusny 2008124Female veterans completing an anonymous cross-sectional survey and enrolled in an outpatient VA clinic.Females
456
Observational;
To examine the difficulties Identifying one’s emotions (alexithymia) in understanding the link between PTSD symptoms and negative health outcome in sexually victimized female veterans
Physical health complaints, VA urgent healthcare utilization, sexual trauma exposure (Traumatic Life Events Questionnaire; TLEQ), PTSD symptom severity, and alexythymia (Toronto Alexithymia Scale; TAS-II)A total of 57.5% reported a lifetime history of sexual trauma; 45.8% reported sexual trauma before age 18; and 32.2% reported sexual trauma after age 18. Hierarchial regression analyses showed that alexithymia independently explained unique variance in participants physical health and their visits to urgent care. These data suggest that emotion recognition problems may contribute to poorer heath outcome in sexually traumatized women veterans beyond what is explained by sexual trauma exposure, health risk behaviors and PTSD. Psychological interventions that enhance emotion identification skills for women who have experienced sexual trauma could improve health perceptions and reduce need for acute health care.
Ross 2008104Nationally-representative sample of female and male community-dwelling adults, age 18 years or older, in 2004 Behavior Risk Factor Surveillance SystemFemales
422
Males
7569
Observational;
To examine whether use of recommended ambulatory care services differs between exclusive and dual VA users
Self-reported use of 18 recommended services for cancer prevention, cardiovascular risk reduction, diabetes management, and infectious disease prevention-Dual users were significantly more likely to be older and white, have higher incomes, have graduated from college, and be insured when compared with exclusive VA users. -After adjustment for patient characteristics, use of recommended services was largely similar among exclusive and dual VA users. -Exclusive VA users reported 14% greater use of breast cancer screening and 10% greater use of cholesterol monitoring among patients with hypercholesterolemia, and 6% lower use of prostate cancer screening and 7% lower use of influenza vaccination. -After adjustment for patient characteristics, exclusive and dual VA users reported similar rates of recommended ambulatory service use.
Rowan 2006140Female and male active duty Air Force Service Members seen in 8 outpatient mental health clinics during a 1-year periodFemales 393
Males
812
Observational;
To examine whether self-referred service members (SMs) are more likely to complete treatment than service members (SMs) referred by supervisors or those undergoing commander-directed evaluations.
Referral source (self, superiors encourages, commander directed), rank, special duty status, diagnostic category, treatment status, recommendationsResults showed significant differences across all variables, with self-referred members being more likely to be older, single, higher ranking, and without special duty status, as well as to have a less significant axis I diagnosis. Self-referred members were less likely to have confidentiality broken and to have career-affecting recommendations made. The implications of these findings, in terms of targeting interventions to increase self-initiated help-seeking behavior, and recommendations for future research are discussed.
Sadler 2005127Stratified random sample of female veterans drawn from a historical national cohort who served in Vietnam, post-Vietnam, or Persian Gulf War eras from VA comprehensive women’s health care registries.Females
540
Observational;
To determine whether there were differences in women veteran’s health status and use of health care services by type of rape (gang, repeated, single, none) that occurred during military service
use of health care services and health statusWomen who experience severe violence during their military service (repeated or gang rape) had significantly impaired physical and emotional health compared with women with a single or no rape (p≤.05). More than a decade after rape during military service, repeatedly raped women were more likely to use inpatient and outpatient mental health services than were women who experienced no rape or a single rape (p≤.05). Gang-rape survivors reported the most severe impairment in physical functioning and general health and demonstrated a trend to seek outpatient medical services.
Shen 2008103National random mail survey of female and male veteran VA enrolleesFemales
3440;
Males
45,008
Observational;
To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage
Use of VA care by insurance status, insurance model (probability of having private insurance), comparisons of insurance effect in different models-VA enrollees with private insurance coverage were less likely to use VA care. -Security selection dominated preference selection and naive models that did not control for selection effects consistently underestimated the insurance effect.
Shen 2005110Medicare-VA dual enrollees with full-year Part B coverage who completed the 1999 National Health Survey of Veterans Enrollees were includedFemales
2167
Males
93,559
Observational;
To examine the association between Veterans Administration (VA)-Medicare dual beneficiaries’ HMO enrollment and factors including sociodemographics, access/attachment to VA, self-reported health status, and characteristics of Medicare HMO markets.
VA-Medicare dual beneficiaries’ HMO enrollmentDual beneficiaries’ aged 65–69; those without college education; and those with VA Priority 5 (low income), 2 and 3 (with less than 50 percent service-connected disability) were more likely to enroll into Medicare HMOs. There was some evidence of favorable selection measured by self-reported health status. Availability of Medicare HMOs and less access to VA care were the major predictors of VA-Medicare dual beneficiaries’ Medicare HMO enrollment.
Sherman 2005118Random sample of female and male veteran smokers in primary care at 18 VA sites in the southwestern and western United StatesFemales
129
Males
1812
Observational;
To examine if 1) there are gender differences among smokers using the Veterans Health Administration (VA) by sociodemographics, health and functional status, and health habits and 2) if there are gender differences in smoking cessation services received within the VA after adjusting for confounding factors.
Receipt of smoking cessation care, including: (a) Doctor or nurse talked about quitting smoking within last year; (b) Doctor referred me to a smoking cessation program with-in last year; (c) Attended smoking cessation program within last year; (d) Doctor prescribed patches or nicotine gum within last yearFemale smokers were younger, more educated, and less likely to be married than male smokers. Women were equally likely to report being advised to quit smoking or referred to a smoking cessation program but were much less likely to report receiving a prescription for nicotine patches (OR 0.5, 95% CI 0.3–0.9). One year later, female smokers were less likely to have successfully quit smoking.
Sherman 2005136Sample veterans (and their female partners) who served in the Vietnam War, had a diagnosis of PTSD and service-connected disability for PTSD, participated in the PTSD program, and current cohabitation with a female partner recruited from two VA medical centers.Females
72
Observational;
To perform an initial needs assessment of partners of Vietnam veterans with combat-related post-tramatic stress disorder (PTSD) and to assess the partners’ current rates of treatment use.
Partner treatment experiences and ratings of treatment needs; partners’ assessment of her need for individual treatment and the partner’s appraisal of family treatment being extremely important (yes/no).Although large majorities of partners rated individual (64%) and family therapy (78%) to help cope with PTSD in the family as extremely or very important, only 28% had received any mental health care in the previous six months. Significant predictors of desire for individual treatment included partner’s anxiety and patient-partner contact, and partner’s age and severity of the patient’s PTSD symptoms were significant predictors of family treatment. The most commonly requested service was a women-only group.
Singh 2007114Female and male veterans who received medical care from an Upper Mid-west Veterans Integrated Service Network (former VISN 13) facility between 10/1/96 and 3/31/98 and completed a mailed surveyFemales
1500
Males
35,000
Observational:
To compare women and men veterans’ health-related quality of life (HRQOL) and VA health care utilization and to see if previously described associations between HRQOL, subsequent VA health care utilization, and mortality in male veterans would generalize to women veterans
HRQOL, VA health care utilization and mortality in the year after survey, gender-specific impact of HRQOL on VA health care utilization and on mortality in the year after the surveyWomen’s effective survey response rate was 52%, men’s 58%. In the following year, 9% of women and 12% of men had at least one hospitalization. One percent of women and 3% of men died in the post-survey year. After adjustment, women’s HRQOL was higher than men’s; for every 10-point decrement in overall physical or mental functioning, women and men had similarly increased risk/odds of subsequently dying, being hospitalized at a VA facility, or making a VA outpatient stop. Among younger women and women who received VA care outside of the Twin City metro area, poorer overall mental or physical health functioning was associated with few primary care stops; among their male counterparts, it was associated with more primary care stops.
Stein 2004128Female patient sample in VA San Diego Health-care System (VASDHS) primary care outpatient clinic.Females
219
Observational;
To determine whether there is an association between sexual assault history and measures of somatic symptoms and illness attitudes in a sample of female Veterans Affairs primary care patients, a group in whom high rates of sexual trauma have been reported.
Traumatic exposure, including sexual assault, physical complaints, healthcare utilization, reported sick days, somatization symptoms, health anxiety.Sexual assault was associated with a significant increase in somatization scores, physical complaints across multiple symptom domains and health anxiety. Sexual assault was also a significant statistical predictor of having multiple sick days in the prior 6 months and of being a high utilizer of primary care visits in the prior 6 months.
These data confirm a strong association between sexual trauma exposure and somatic symptoms, illness attitudes and healthcare utilization in women.
Vogt 2006101Nationally representative sample of female veterans who used VA care (i.e., current and former users) and were a subset of National Registry of Women VeteransFemales: 942Observational;
To document perceived and/or actual barriers to care in a nationally representative sample of female veterans and examine associations with VA use.
Ratings of VA care and care in other facilities; ratings of barriers to VA care (i.e., availability of services, physician sensitivity and skill, logistics of care, and facility/physical environment characteristics).The greatest barrier to the use of VA care was problems related to ease of use. In the model with background characteristics plus all 4 barrier domains, only availability of services (OR 0.49, 95%CI 0.29–0.80) and facility/physical environment characteristics remained (OR 1.93, 95%CI 1.16–3.19) retained significant associations with VA use.
Wakefield 2007106Female and male veteran VA users and nonusers from one Midwestern VAMCFemales
7
Males
35
Observational;
To examine veterans’ perceptions of problems and benefits of outsourcing inpatient care from Veterans Affairs (VA) hospitals to private sector hospitals.
reasons veterans choose whether or not to use VA servicesThe focus groups identified six domains related to why veterans use or do not use VA services; cost, access, quality of care, contract (i.e., covenant between veterans and the U.S. government), veteran milieu, special needs. With the exception of veteran milieu, these same domains were identified with regard to the potential positive and negative impacts of outsourcing inpatient care to non-VA hospitals; two additional outsourcing domains were also identified, choice and discrimination. Cost was the first reason veterans gave for using the VA; access and quality were In general, veterans perceived more advantages than disadvantages to outsourcing VA care but still expressed significant concerns related to outsourcing.
Washington 200751VA-eligible women veterans in Los Angeles, California formed 6 focus groups: 4 with women who used VA health care (VA users) and 2 with women who have never used or have not used VA in the past 5 years (nonusers)Females
51
Observational;
To determine women veterans’ perspectives and decision-making about VA health care use
Patient reported themes on information needs, access, gender appropriateness of services and gender-related aspects of care, quality of careBarriers to VA use for both VA users and nonusers included lack of information about eligibility and available services. Nonusers often assumed the VA did not provide women’s health care. All groups emphasized they required a health care system focused on quality and sensitivity to women’s health issues. However, users and nonusers differed in perceptions of VA quality. VA environment and quality concerns led many women to limit their VA use to women’s clinics.
Washington 2006102Female veterans who participated in a cross-sectional telephone survey of 2,174 VA users and VA-eligible non-usersFemales
2174
Observational;
To determine why women veterans use or do not use VA health care
Reasons for choice of VA versus non-VA health care setting, knowledge and perceptions of VA, independent predictors of type of ambulatory care use, demographics and health statusReasons cited for VA use included afford-ability (67.9%); women’s health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for sociodemographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use.
Washington 200646National sample of VA sites serving 400 or more women veterans in fiscal year 2000Nonpatient
118
To assess the availability of women’s health care specialists for emergency gynecological problems (GYN) and for emergency mental health conditions specific to women (WMH).Availability of women’s health care specialists for emergency gynecologic problems (GYN) and emergency mental health (MH) conditions specific to women during clinic hours and after hours.-The majority of sites had GYN and MH specialists available for emergencies during clinic hours (64.4% and 82.7% of sites, respectively).
-Availability of specialists after hours for GYN emergencies was 39.8%, for MH emergencies was 51.7%.
-Two significant predictors: separate women’s health clinic was associated with availability of emergency GYN services (beta: 0.279, p=0.023), and lower local managed care penetration was associated with availability of emergency MH conditions specific to women (beta: -0.282, p=0.024).
Zeber 2007105Secondary data on Female and male veterans contained in the National Psychoses Registry from June 1, 2000, through September 30, 2003, for all veterans diagnosed with schizophrenia and receiving healthcare through the Department of Veterans Affairs.Females
4275
Males
76,393
Observational;
To assess the effect of the 200 Veterans Millennium Health Care Act, which raised pharmacy copayments from $2 to $7 for lower-priority patients, on medication refill decisions and health services utilization among vulnerable veterans with schizophrenia
total prescription fills, medical and psychotropic fills separately, outpatient visits, psychiatric admission, inpatient days among those admitted, and pharmacy costsTotal prescriptions and overall pharmacy costs leveled among veterans with copayments after the medication cost increase. However, psychiatric drug refills dropped substantially, nearly 25%. Although outpatient visits were unaffected, psychiatric admissions and total inpatient days increased slightly, particularly 10–20 months after the policy change.
Zinzow 2008126Random sample of female and male primary care users at one of four Veterans Affairs Medical Centers (Charleston or Columbia, SC; Tuscaloosa or Birmingham, AL)Female
173
Male
816
Observational; To examine the nature and prevalence of sexual assault (SA), as well as its relationship to psychiatric sequelae and service use, among the veteran populationSexual assault characteristics, trauma history, psychiatric diagnoses and global health functioning, service use-Lifetime prevalence of SA was 38% among women and 6% among men. Of veterans reporting a history of SA, most experienced child sexual abuse and sexual re-victimization.
-SA victims had a more extensive trauma history and demonstrated greater psychological impairment in comparison to veterans reporting other types of trauma.
-Only 25% of male SA survivors and 38% of female SA survivors used mental health services in the past year.

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