Quality of hospital medicine care in Veterans Affairs hospitals versus non-Veterans Affairs hospitals: A systematic review of comparative studies.

BackgroundThe Veterans Health Administration (VA) serves Veterans in the nation’s largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic.MethodsWe searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps.ResultsThirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed.DiscussionVA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.

To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care). VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

The extent to which female veterans are willing to seek Veterans Health Administration (VHA) and non-VHA care when they are suicidal or experiencing mental health (MH) concerns is unknown. The objectives of this study were to: (1) examine whether current, past, and never VHA using female veterans' willingness to seek VHA care differs from their willingness to seek non-VHA care if suicidal or experiencing MH symptoms; (2) examine if VHA use, military sexual trauma, and suicidal ideation and attempt are associated with female veterans' willingness to use VHA and non-VHA care when experiencing suicidal thoughts or MH symptoms. A cross-sectional anonymous survey. Four hundred thirty nine female veterans, including current, past, and never VHA users were included. General Help-Seeking Questionnaire, Self-Injurious Thoughts and Behaviors Interview, and the VA Military Sexual Trauma Screening Questions. Current VHA users reported more willingness to use VHA than non-VHA care; conversely, past and never VHA users reported less willingness to use VHA care relative to non-VHA care. Military sexual assault and none or past VHA use were associated with lower willingness to use VHA care if suicidal or experiencing MH symptoms. In contrast, those with none or past VHA use reported greater willingness to use non-VHA care if suicidal or experiencing MH symptoms, while prior suicide attempt was associated with lower willingness. Ensuring that acceptable and effective suicide prevention services are available to female veterans in both VHA and community settings is critical. Increasing help-seeking intentions among female veterans who have attempted suicide or experienced military sexual assault is also essential.

Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup.

ABSTRACTBACKGROUNDWhile prior research characterizes women Veterans’ barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.OBJECTIVESTo compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.DESIGNCross-sectional, population-based 2008–2009 national telephone survey.PARTICIPANTSSix hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.MAIN MEASURESPopulation weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.KEY RESULTSFifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.CONCLUSIONSWe found high VA attrition despite recent advances in VA care for women Veterans. Women’s attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.

Comparing Quality of Surgical Care Between the US Department of Veterans Affairs and Non-Veterans Affairs Settings: A Systematic Review.

BackgroundVeterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans’ social determinants of health (SDOH) to facilitate Veterans’ transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care.MethodsThe ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams.We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping.DiscussionThe ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans’ SDOH. This intervention will provide an essential service for effective care coordination.

Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care. We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients. This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients. In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009. An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates. Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality. Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.

POTENTIAL AND PROMISE OF PARTNERED RESEARCH Translation of research evidence into routine practice continues to take decades, undermining the potential promise of new evidence-based treatments and care models for improving population health.1 Yet research traditions often reward "ivory towers" of academic research excellence in the absence of demonstrated impacts on health and health care beyond those achieved in pristine, controlled settings, unlike those where most Americans receive their health care.2,3 As a result, our research enterprises frequently yield research evidence of uncertain applicability to routine care, making knowledge transfer and implementation difficult at best for successful translation of published research into evidence-based policy or practice improvement.4,5 Partnered research has been proposed as a promising alternative to the status quo, with the potential to produce more directly actionable findings more quickly in more diverse contexts amenable to implementation and adaptation.6 In a partnered research paradigm, researchers engage nonresearch partners in the definition of the research questions, approaches to study design and methods, and interpretation and application of study results.7 Depending on the targets of the research intervention, partners may include patients, their families, providers, practices, managers, and/or policymakers in local, regional, and/or national contexts.8 Although such multilevel engagement is considered a novel approach by some, involving people in decision making has long been found to increase their willingness to implement those decisions.9 There is no foundation for thinking that decision making around the many actions required for adoption, implementation, and spread of research evidence would be tangibly different.10 As a result, lack of embedded partnerships likely undermines meaningful research impacts on the health and health care of the population.11 FOSTERING PARTNERED RESEARCH IN THE VETERANS HEALTH ADMINISTRATION (VA) The VA, the largest integrated health care delivery system in the United States, established an intramural health services research and development (HSR&D) program over 40 years ago. This embedded research program of clinician investigators and social scientists, with academic ties to many of the country's top research universities, is focused on addressing VA health care priorities that ultimately help to improve health care for Veterans and the nation. Given this mission in the context of operating within the VA health care system, VA HSR&D is uniquely positioned—like similarly embedded research programs, for example, at Kaiser and Group Health—to study the potential and promise of partnered research on patient, provider, and system outcomes.12 In their editorial, "Partner or Perish," Kilbourne and Atkins13 argue for breaking down research "silos" through early involvement with clinical and operations decision makers, demonstration of value-added research, mutually beneficial bidirectional engagement, and input from different stakeholders. The VA Quality Enhancement Research Initiative (QUERI) is characteristic of early efforts to build effective research-clinical partnerships in service of implementation science and increased research impacts.14 Although QUERI has nearly 15 years' experience in implementation science, VA HSR&D Service, which represents a much larger portfolio, had not yet begun to systematically encourage researchers to adopt more partnered approaches to research. To make this change in emphasis, HSR&D leaders launched a new initiative incentivizing partnered research: the Collaborative Research to Advance Transformation and Excellence (CREATE) Initiative.15 CREATEs were designed to fundamentally change the partnership equation by making local, regional, and/or national policy or operations leaders a requirement of the research development process around topical areas of high-value to the VA system. Partners also had to demonstrate active participation, leverage research funds where appropriate, and commit to implementation of research findings. In turn, researchers worked collaboratively with partners to develop 3–5 projects linked to an overarching impact goal, designed to be achievable within 5 years. Multisite collaborations were encouraged among midlevel to senior investigators to increase potential for success given the experimental nature of the initiative. After 2 years of proposal and partnership development, VA HSR&D funded 10 CREATEs, including one focused on women Veterans' (WVs) health, which are now in varying stages of progress on their 4–5-year trajectories.16 VA WOMEN'S HEALTH CREATE AS AN EXEMPLAR OF PARTNERED RESEARCH Why WVs' Health as a Focus? Historically an extreme numerical minority in VA settings, WVs are now the fastest growing segment of new VA users, doubling in number since 2000, projected to be 10% of all Veteran users by 2018, and already 20% of new military recruits.17 These changing demographics have hastened VA's need to address a wide spectrum of services to meet WVs' complex needs, including gender-specific care.18 The predominance of men in VA settings has also created unintended consequences for the VA workforce, limiting exposure to female patients, increasing need for clinical retraining to ensure proficiencies in conditions common to women (eg, breast and routine gynecologic care) and highlighting the need for VA culture change.18 WVs' high rates of military sexual trauma have underscored the importance of gender-sensitive care environments.19 Achieving gender-sensitive comprehensive care for WVs has, therefore, been a top VA priority.19 Establishing a VA Policy Anchor for Research Development In response to a growing body of evidence demonstrating WVs' access barriers, service gaps, and care fragmentation, VA released Handbook 1330.01 on "Health Care Services for Women Veterans" in 2010 (Fig. 1). The Handbook codified organizational responsibilities at all VA operational levels, defining VA's expectations that "each VA facility must ensure that eligible WVs have access to comprehensive medical care, including care for gender-specific conditions and mental health conditions … comparable to care provided for male Veterans." Further, "all enrolled WVs need to receive comprehensive primary care (PC) from a designated women's health PC provider who is interested and proficient in the delivery of comprehensive PC to women, irrespective of where they are seen … and regardless of the number of WVs utilizing a particular facility." Such care must address fragmentation by including complete PC and care coordination by 1 PC provider in a single site (ie, "one-stop shopping") in environments sensitive to women's needs, safety, and dignity.FIGURE 1: Overview of the key elements of VA policy on delivering comprehensive health care to women Veterans.Although research provided evidence for the need for change, implementation and achievement of the Handbook's tenets would be difficult to accomplish. The Women's Health CREATE team worked in partnership with VA Women's Health Services (WHS), the national office responsible for the breadth of WVs' care (eg, PC, specialty care, mental health care), to develop 5 core studies designed to generate the evidence base for accelerating implementation of comprehensive care for WVs. Component CREATE Projects Component projects were developed among collaborating investigators in partnership with WHS and other partners with oversight over the policy and operational areas that individual projects involved. For example, leaders of the VA Primary Care Program Office were involved as advisors for a project planning to tailor PC to WVs' needs. Leaders of VA women's mental health services collaborated with PIs to ensure incorporation of measures related to mental health care across all studies, creating a thematic emphasis capable of leveraging the CREATE to answer key questions for VA Mental Health Services. Table 1 provides a summary of the 5 component projects' aims and study approaches.TABLE 1: Overview of the Women's Health CREATE's Component ProjectsThese projects tackle issues underlying achievement of comprehensive care organically, individually complete but with marked cross-project leveraging of resources and synergy. The first project examines patient, provider, organizational, and area determinants of WVs' attrition from VA care, exploring the degree to which access to comprehensive care is driving experience and behavior. The second project measures comprehensive care implementation nationwide, examining how attributes of comprehensiveness may influence WVs' access and care quality. The third project tests evidence-based quality improvement approaches to adapting VA's medical home model (PACT) to WVs' comprehensive care needs. The fourth project seeks to increase comprehensive care for WVs seen at community-based clinics through virtual consultation and education. And the fifth project examines implications of achieving comprehensive care through use of VA-paid care in the community, evaluating quality, and coordination of outsourced care. CREATE Oversight and Management: Achieving a Sum Greater Than its Parts The Women's Health CREATE is overseen by a national Executive Steering Committee (ESC), a national Women Veterans Council and VA HSR&D Service through intermittent in-person meetings and calls. The ESC reviews progress, provides critical feedback, and actively identifies policy and practice implications of study findings, while keeping researchers apprised of new initiatives and recommending potential spin-off projects, including those funded by VA operations. The ESC has requested more frequent interactions with CREATE investigators, including project-specific "deep dives" to enhance feedback detail and potential impacts. The Women Veterans Council currently focuses on strategic planning around patient engagement and dissemination. VA HSR&D Service participates in the ESC in ex-officio roles, requests evaluative information, and helps troubleshoot fiscal and regulatory issues (eg, union notification to facilitate VA staff participation). Additional monthly calls with WHS leadership and other partners ensure attention to their respective policy/operations priorities and information needs. Individual studies have additional approaches to partner engagement. For example, one study has a project-specific advisory board that engages leaders from the VA Office of Specialty Care Services and the VA network in which the majority of the designated women's health providers participate, in addition to experts in virtual strategies for educating and supporting providers at a distance. Component projects also benefit from synergistic management, including routine cross-project monitoring; generation of cross-project briefing summaries for VA HSR&D Service and partners; systematic cross-project sharing of techniques, methodological advances, and data, where appropriate; and continuous review of planned products. This centralized management is funded by WHS as primary CREATE partner, adding another layer of "skin in the game," in addition to supporting development of CREATE-level theoretical, methodological, and impact-related products. Anchoring component projects in a unified conceptual and theoretical framework applying diffusion of innovation theory will enhance the ability to synthesize lessons across projects in meaningful ways (Fig. 2).FIGURE 2: VA Women's Health CREATE Conceptual Model: using research to accelerate implementation of comprehensive care for women Veterans through diffusion of innovation.Research-Clinical Partnerships: "Not a Shotgun Wedding" Although the Women's Health CREATE has just completed its second year of operation, the extent and quality of the research-clinical partnerships underlying its development and management are particularly strong. For example, research engagement with WHS—present and past—has been active for 15+ years, including invitations to partners to serve in project advisory roles and dissemination of manuscripts/reports to them as research findings become available. WHS has also funded just-in-time projects over the years, engaging researchers in program evaluation of new initiatives (eg, telegynecology), often seeding new areas of work that ultimately lead to new research funding and creating incentives for researchers to pay heightened attention to VA policy priorities. The Women's Health CREATE also benefits from a 10-year history of collaborative research development, beginning with establishment of the first VA women's health research agenda and first systematic review of WVs' research in 2004, which outlined knowledge gaps and made recommendations for enhancing VA women's health research capacity and focus.20,21 Recommendations were acted on by VA HSR&D through WVs' research solicitations, integration of women's health expertise in scientific review panels, and eventual funding of the VA Women's Health Research Network (WHRN) in 2010. WHRN comprised 2 capacity-building arms. The first reflected Consortium development, arming VA investigators with the knowledge, methods, and means to support inclusion of women in VA research and/or to focus on high-priority WVs' topics. The second reflected development of a multisite practice-based research network to foster inclusion of WVs by creating a network of VA facilities prepared to enroll women and involve VA providers and staff in practice-based research.22 Both arms were central to mounting a meaningful, partnered approach to CREATE development among teams of researchers across the country with a decade of collaborative experience under their belts. USING PARTNERED RESEARCH TO TRANSFORM VA CARE To achieve the vision for personalized, proactive, patient-driven health care for Veterans, the VA will require ongoing clinical innovation, research, and education.23 Practicing partnered research through new approaches to multilevel engagement, like the CREATE, holds significant promise for forming robust, sustainable strategies for more rapidly integrating rigorous science into quality improvement and transforming the VA into a next generation learning organization.24,25 ACKNOWLEDGMENTS The author thanks Angela Cohen, MPH, for her superlative cross-CREATE management and Linda Lipson, MA, VA HSR&D Service Scientific Program Manager for the Women's Health CREATE and the larger women's health research portfolio, among other key topical areas. On behalf of all of the CREATE principal investigators, the author would like to particularly acknowledge Patricia Hayes, PhD, Chief Consultant, VHA Women's Health Services, primary partner for the Women's Health CREATE, without whom the work described here would have occurred.

While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Transition from military to VHA care: Psychiatric health services for Iraq/Afghanistan combat-wounded

The 2014 Veterans Access, Choice and Accountability Act was intended to improve Veterans' access to timely health care by expanding their options to receive community care (CC) paid for by the Veterans Health Administration (VA). Although CC could particularly benefit rural Veterans, we know little about rural Veterans' experiences with CC. The objective of this study was to compare rural Veterans' experiences with CC and VA outpatient health care services to those of urban Veterans and examine changes over time. Retrospective, cross-sectional study using data from the Survey of Healthcare Experiences of Patients (SHEP) and VA Corporate Data Warehouse. Subjects: All Veterans who responded to the SHEP survey in Fiscal Year (FY) 16 or FY19. Outcomes were 4 measures of care experience (Access, Communication, Coordination, and Provider Rating). Independent variables included care setting (CC/VA), rural/urban status, and demographic and clinical characteristics. Compared with urban Veterans, rural Veterans rated CC the same (for specialty care) or better (for primary care). Rural Veterans reported worse experiences in CC versus VA, except for specialty care Access. Rural Veterans' care experiences improved between FY16 and FY19 in both CC and VA, with greater improvements in CC. Rural Veterans' reported comparable or better experiences in CC compared with urban Veterans, but rural Veterans' CC experiences still lagged behind their experiences in VA for primary care. As growing numbers of Veterans use CC, VA should ensure that rural and urban Veterans' experiences with CC are at least comparable to their experiences with VA care.

BackgroundThe Department of Veterans Affairs' Veterans Health Administration (VHA) provides a health care safety net to veterans. This study examined changes in characteristics of veterans using the VHA health care system between 1996 and 1999 when VHA implemented major organizational changes to improve access of ambulatory care and to provide care to more veterans.MethodsThe study used two cross-sectional samples of the Medical Expenditures Panel Survey (MEPS), a national representative survey, in 1996 and 1999. The 1996 MEPS survey included 1,944 veterans and the 1999 MEPS survey included 1,974 veterans. There were 534 veterans and 740 veterans who used VHA services in 1996 and 1999, respectively.ResultsThe proportion of veterans using the VHA system increased from 12.4% in 1996 to 14.6% in 1999. In both years, veterans were more likely to use VHA care if they were older, male, less educated, uninsured, unemployed, and in fair or poor health status. Only two variables, marital status and income, were different between the two years. Married veterans were more likely to use VHA care in 1999, but not in 1996. Veterans with higher incomes had greater odds of using VHA care in 1996, but there was no significant association between income and VHA use in 1999.ConclusionCharacteristics of VHA users did not fundamentally change despite the reorganization of VHA health care delivery system and changes in eligibility and enrollment policy. The VHA system maintains its safety net mission while attracting more veterans.

Among community-dwelling adults ages 65 and older, approximately 11% have experienced elder mistreatment (EM), including physical, emotional or sexual abuse, neglect, or financial exploitation. EM research typically focuses on this age group; however, Veterans receiving Veterans Health Administration (VHA) care have increased earlier morbidity, which may accelerate the impacts of EM. Using a cohort of all VHA Veterans 50 years and older with VHA use in 2018-2020, we examined correlates of EM. ICD-10 codes from clinical encounters identified Veterans with indications of EM (n=4,427). A 10% sample of Veterans without indications of EM was selected for comparison (n=530,535). Logistic regression compared EM+ Veterans to the comparison sample and assessed overall demographic and clinical differences as well as differences by age, i.e. 50-64 versus 65 and older. Overall, female gender (OR=5.3, 95% CI=4.3-6.5), non-white race/ethnicity (OR=1.7, CI=1.5-1.9), dementia (OR=3.0, CI=2.6-3.5), PTSD (OR=2.0, CI=1.6-2.5), anxiety (OR=1.3, CI=1.0-1.5), military service connected disability status (OR=1.3, CI=1.1-1.5), and higher Elixhauser medical morbidity scores (OR=1.1, CI=1.1-1.1) were associated with EM. Prior year ER visits (OR=28.0, CI=23.6-33.4), inpatient stays (OR=14.0, CI=11.5-17.0), and mental health visits (OR=26.1, CI=22.2-30.6) also predicted EM+ status. Forty-six percent of VHA Veterans with indicators of EM were aged 50-64. For these Veterans, female gender, PTSD, service connection, and mental health visits were associated with increased risk of EM compared to Veterans 65+. Findings highlight clinical correlates of EMs among Veterans in VHA care. Increased awareness of EM risk factors is warranted and may inform VHA efforts for EM prevention, detection and intervention.