National Sample Of Veterans Research Articles

Regional, Geographic, and Racial/Ethnic Variation in Glycemic Control in a National Sample of Veterans With Diabetes

OBJECTIVEWe performed a retrospective analysis of a national cohort of veterans with diabetes to better understand regional, geographic, and racial/ethnic variation in diabetes control as measured by HbA1c.RESEARCH DESIGN AND METHODSA retrospective cohort study was conducted in a national cohort of 690,968 veterans with diabetes receiving prescriptions for insulin or oral hypoglycemic agents in 2002 that were followed over a 5-year period. The main outcome measures were HbA1c levels (as continuous and dichotomized at ≥8.0%).RESULTSRelative to non-Hispanic whites (NHWs), HbA1c levels remained 0.25% higher in non-Hispanic blacks (NHBs), 0.31% higher in Hispanics, and 0.14% higher in individuals with other/unknown/missing racial/ethnic group after controlling for demographics, type of medication used, medication adherence, and comorbidities. Small but statistically significant geographic differences were also noted with HbA1c being lowest in the South and highest in the Mid-Atlantic. Rural/urban location of residence was not associated with HbA1c levels. For the dichotomous outcome poor control, results were similar with race/ethnic group being strongly associated with poor control (i.e., odds ratios of 1.33 [95% CI 1.31–1.35] and 1.57 [1.54–1.61] for NHBs and Hispanics vs. NHWs, respectively), geographic region being weakly associated with poor control, and rural/urban residence being negligibly associated with poor control.CONCLUSIONSIn a national longitudinal cohort of veterans with diabetes, we found racial/ethnic disparities in HbA1c levels and HbA1c control; however, these disparities were largely, but not completely, explained by adjustment for demographic characteristics, medication adherence, type of medication used to treat diabetes, and comorbidities.

Variation in Quality of Care Indicators for Diabetes in a National Sample of Veterans and Non-Veterans

Veterans have a disproportionately higher burden of type 2 diabetes. It is unclear whether veterans with diabetes have better self-care behaviors or receive better quality of care than non-veterans. The objective was to examine differences in diabetes care between veterans and non-veterans. Data analysis was performed with respondents from the 2003 Behavioral Risk Factor Surveillance Survey (n = 21,111 with diabetes). Veterans were those who reported U.S. military service and no longer on active duty. Self-care behaviors included daily fruit and vegetable intake, physical activity level, self-foot checks, and home glucose testing. Quality of care indicators included provider actions over the past 12 months (2+ office visits, 2+ glycosylated hemoglobin checks, 1+ foot exams, 1+ dilated eye exams, daily aspirin use, receiving flu or pneumonia vaccine). Multiple logistic regression using STATA version 10 (Stata Corp., College Station, TX) analyzed differences by veteran status on each quality indicator, controlling for sociodemographics and diabetes education. Veterans comprised 14.2% of the sample, and 12.4% had diabetes compared to 6.7% of non-veterans. In final adjusted models, veterans were significantly more likely to check their feet (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.09, 1.64), get a dilated eye exam (OR 1.36, 95% CI 1.11, 1.66), receive aspirin (OR 1.31, 95% CI 1.04, 1.65), get a flu shot (OR 1.32, 95% CI 1.09, 1.61), and ever get a pneumonia shot (OR 1.38, 95% CI 1.12, 1.70). Veterans appear to have better self-care behaviors and receive better preventive care than non-veterans. However, future efforts need to focus on boosting self-care to improve diabetes outcomes.

Effect of Veterans Administration Use on Indicators of Diabetes Care in a National Sample of Veterans

Diabetes poses a serious health burden, of which veterans have a disproportionate share. Few data exist regarding differences in self-care behaviors and provider-based quality of care indicators among a large sample of veterans. The objective of this study was to determine the effect of Veterans Affairs (VA) use on diabetes quality of care indicators among veterans. A cross-sectional analysis was done on data from 36,525 veterans in the 2003 Behavioral Risk Factor Surveillance Survey. VA use was defined as receiving some or all health care from a VA facility in the previous 12 months. Diabetes quality indicators such as two or more provider visits, two or more hemoglobin A1c tests, and flu and pneumonia shots were compared between VA users and non-VA users. The independent effect of VA use on each quality indicator was analyzed with multiple regression using STATA version 10 (Stata Press, College Station, TX) to account for the complex survey design and yield population estimates. Among veterans with diabetes, 26.8% were VA users. The only significant difference between VA users and non-VA users was that VA users were significantly more likely to check their feet one or more times daily (75.7% vs. 68.5%, P = 0.015). In final adjusted models, VA users were at least twice as likely as non-VA users to have foot exams by a provider (odds ratio 2.59) and receive flu and pneumonia shots (odds ratio 2.30 and 2.05, respectively). VA users were also more likely to have two or more provider visits, dilated eye exams, and two or more hemoglobin A1c tests than non-VA users. Key quality indicators for diabetes care were better among veterans getting some or all of their care from VA facilities, suggesting more effective care strategies. However, interventions should identify and perpetuate excellent self-care behaviors to more substantially impact adverse diabetes-related outcomes.

Equity in Veterans Affairs Disability Claims Adjudication in a National Sample of Veterans

To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims. Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework. Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects. Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

Gender Differences in Veterans Health Administration Mental Health Service Use: Effects of Age and Psychiatric Diagnosis

The objective of this study was to compare gender differences in mental health disease burden and outpatient mental health utilization among veterans utilizing Veterans Health Administration (VHA) mental health services in fiscal year 1999 (FY99), after the first Gulf War and significant restructuring of VHA services. We used logistic regression to examine the relationships among gender, age, diagnostic groups, and utilization of mental health and specialty mental health services in a national sample of veterans. The sample included 782,789 veterans with at least 1 outpatient visit in the VHA in FY99 associated with a mental health or substance abuse (SA) diagnosis. Subgroup analyses were performed for 4 diagnostic categories: 1) posttraumatic stress disorder (PTSD), 2) SA disorders, 3) bipolar and psychotic disorders, and 4) mood and anxiety disorders. Younger women veterans (<35 years old) were significantly less likely and older women (> or =35) more likely to use any mental health services in comparison with their male counterparts. Similar findings were observed for younger women diagnosed with SA or mood and anxiety disorders, but not among veterans with PTSD or bipolar and psychotic disorders, among whom no there were no gender or age differences. In the case of specialized services for SA or PTSD, women younger than 55 with SA or PTSD were significantly less likely to use services than men. Women veterans underutilized specialty mental health services in relation to men but receipt of mental health care overall in FY99 varied by age and diagnosis. Examining gender differences alone, without taking other factors into account, may not provide an adequate picture of women veterans' current mental health service needs.

Physical Activity in a National Sample of Veterans

To describe and compare the prevalence of physical activity (PA) in relation to veteran status and use of Department of Veterans Affairs (VA) facilities. Data were obtained from the 2003 Behavioral Risk Factor Surveillance System surveys of US adults. Veteran status, VA health care use, and PA were determined in 245,564 adults. Individuals were classified as inactive, insufficiently active, or meeting recommendations for moderate or strenuous PA. To adjust for confounding, we used model-based direct adjustment and chi-square tests corrected for the survey design. After adjusting for age and gender, the prevalence of inactivity was significantly lower (16.2% vs 20.5%), and meeting PA recommendations was significantly greater (46.0% vs 42.0%) in veterans than in nonveterans (P < 0.0001). Compared with veterans who did not obtain their health care from the VA, VA users were more likely to be inactive (20.8% vs 14.7%) and less likely to be insufficiently active (34.1% vs 38.2%) or meet recommendations (45.1% vs 47.1%; P < 0.0001). Differences in PA levels between veterans and nonveterans and between VA users and nonusers did not change substantially after additional adjustment for education, race/ethnicity, and smoking. Despite the high level of PA required of active duty military personnel, only a minority of veterans met PA recommendations, and the prevalence of inactivity was particularly high in VA users. These findings suggest a large potential to increase PA and improve health in VA users.

Alcohol Misuse and Multiple Sclerosis

Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis. Objective To describe the prevalence of alcohol misuse and medical advice to reduce drinking in a national sample of veterans with multiple sclerosis (MS). Design Cross-sectional cohort study linking computerized medical record information to mailed survey data from 2004 through 2006. Setting Veterans Health Administration (VHA). Participants Two thousand six hundred fifty-five of 4929 veterans with MS who received services in VHA between 2004 and 2006 and also a survey questionnaire (53.9% response rate). Interventions Not applicable. Main Outcome Measures Demographic information, Short-Form 12-Item Health Survey Mental Component Summary and Physical Component Summary, Alcohol Use Disorders Identification Test Consumption questions, and questions assessing depressive symptoms and the receipt of alcohol-related advice from a medical professional. Results Among all survey respondents with MS, the prevalence of alcohol misuse for the sample was 13.9% (confidence interval [CI], 12.5–15.2), with 11.9% (CI, 10.6–13.2) and 2.0% (CI, 1.4–2.5) of participants scoring in the mild/moderate and severe range of alcohol misuse, respectively. In contrast to community samples there was no difference in prevalence by sex. In multivariate logistic regression, age younger than 60 years (<50y; adjusted odds ratio [AOR]=1.66; CI, 1.17–2.37, and 50–59; AOR=1.64; CI, 1.19–2.27), employment (AOR=1.54; CI, 1.06–2.24) and better physical health (AOR=1.02; CI, 1.01–1.04) were associated with a higher likelihood of alcohol misuse. Among persons who screened positive for alcohol misuse, only 26.2% (CI, 21.5–30.9) reported they had received advice from a medical provider in the past year to decrease or abstain from drinking. Self-report of advice was more likely among those endorsing severe misuse (AOR=3.65; CI, 1.85–7.17) and less likely among those with better mental health (AOR=0.97; CI, 0.94–1.00). Conclusions Despite the numerous health and social consequences of alcohol misuse, routine screening and intervention for people with MS remain uncommon. Brief screening and advice to reduce or refrain from alcohol use can be accomplished in as little as 5 minutes and can be incorporated into the regular course of medical care.

Exercise and Quality of Life Among People With Multiple Sclerosis: Looking Beyond Physical Functioning to Mental Health and Participation in Life

Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life. Objective To describe the prevalence of exercise in a national sample of veterans with multiple sclerosis (MS) and the association of exercise with quality of life, including physical health, mental health, and participation restriction. Design Cross-sectional cohort study linking computerized medical records to mailed survey data from 1999. Setting Veterans Health Administration. Participants Veterans with MS (N=2995; 86.5% men) who received services in the Veterans Health Administration and returned survey questionnaires. Interventions Not applicable. Main Outcome Measures Demographic information, Veteran RAND 36-Item Health Survey (VR-36), self-reported exercise frequency. Results Among all survey respondents with MS, only 28.6% (95% confidence interval, 26.9–30.2) endorsed any exercise. In adjusted logistic regression, exercise was associated with younger age, more education, living alone, lower levels of bodily pain, and higher body mass index. After adjusting for demographic variables and medical comorbidities, exercise was associated with better physical and mental health. People who exercised reported they had better social functioning and better role functioning (participation in life despite physical and emotional difficulties). Conclusions Exercise in veterans with MS is uncommon. In the context of chronic illness care, the identification of exercise patterns and promotion of physical activity may represent an important opportunity to improve mental health and quality of life among people with MS. Intervention should address factors associated with lower rates of exercise including age, education, and pain.

Understanding Associations Between Serious Mental Illness and Hepatitis C Virus Among Veterans: A National Multivariate Analysis

Hepatitis C virus (HCV) is a leading cause of hepatocellular carcinoma and cirrhosis in the United States and is known to be transmitted via pathways associated with substance use (e.g., injection drug use and intranasal drug use). Although individuals with serious mental illness (SMI) have a high prevalence of HCV, the nature of this relationship is unclear and is the subject of this investigation. The authors determined unadjusted and adjusted recorded prevalence of HCV among a national sample of veterans with and without SMI. HCV was recorded in 8.1% of patients with bipolar disorder, 7.1% of patients with schizophrenia, and 2.5% of patients without SMI. Substance use increased HCV risk among SMI patients; patients with bipolar disorder had greater risk than patients with schizophrenia. Efforts to address HCV among patients with serious mental illness and co-occurring substance abuse are warranted.

Gender Differences in Health-Related Quality of Life for Veterans With Serious Mental Illness

This study assessed gender differences in health-related quality of life (HRQOL) in a national sample of veterans with serious mental illness. Data were analyzed from the Large Health Survey of Veterans, which was mailed to a national random sample of veterans in 1999. The linear and logistic multiple regression analyses included 18,017 veterans with schizophrenia, schizoaffective disorder, or bipolar disorder who completed the survey. HRQOL was measured by using the various subscales of the 36-Item Short Form of the Medical Outcomes Study (MOS SF-36) (mental component summary, physical component summary, and activities of daily living) and by questions assessing self-perceptions of health status. The sample was 7.3% female, 75.7% white, and 83.8% unemployed. Mean+/-SD age was 54.3+/-12.2 years. After the analysis adjusted for sociodemographic characteristics, health status, and other variables, compared with male veterans, female veterans with serious mental illness had lower scores on the SF-36 physical component summary (indicating worse symptoms), were more likely to report that they were limited "a lot" in activities of daily living, and had more pain. However, female respondents were more likely to have a positive outlook on their health. Among veterans who received a diagnosis of serious mental illness from providers of the Department of Veterans Affairs, women reported substantially poorer HRQOL than men across several domains but women reported better self-perceived health. Attention to the particular needs of female veterans with serious mental illness is imperative as the numbers of female veterans continue to increase.

Smoking Among Veterans With Multiple Sclerosis: Prevalence Correlates, Quit Attempts, and Unmet Need for Services

Turner AP, Kivlahan DR, Kazis LE, Haselkorn JK. Smoking among veterans with multiple sclerosis: prevalence, correlates, quit attempts, and unmet need for services. Objective To describe the prevalence and correlates of smoking as well as quit attempts and unmet need for smoking cessation services in a national sample of veterans with multiple sclerosis (MS). Design Cross-sectional cohort study linking computerized medical record information to mailed survey data from 1999. Setting Veterans Health Administration (VHA). Participants Sixty-four percent (2994/4685) of veterans with MS who received services in VHA and also returned survey questionnaires, as well as a 20% random subsample (n=569) who completed a more extensive assessment of smoking. Interventions Not applicable. Main Outcome Measures Items assessing smoking, quit attempts, and unmet need for smoking services. Results Among all survey respondents with MS, 28.5% (95% confidence interval [CI], 26.9–30.2) endorsed current smoking. Of extended survey respondents, 54.5% (95% CI, 46.6–62.1) reported a quit attempt in the past year, and 59.0% (95% CI, 51.1–66.4) reported not getting needed services for smoking in the past year. In fully adjusted logistic regression, smoking was associated with younger age, lower levels of education, being unmarried, higher levels of physical pain, and poorer mental health. A quit attempt was associated with higher levels of education and greater pain intensity. Conclusions Smoking among veterans with MS is common, with rates similar to those for other veterans. There is substantial need for cessation services. Cessation interventions should address correlates of smoking including pain, poorer mental health, and social isolation.

Understanding Associations Between Serious Mental Illness and HIV Among Patients in the VA Health System

This study compared the recorded prevalence of HIV among veterans with and without serious mental illness. This cross-sectional study examined data from a national sample of veterans who received a diagnosis of serious mental illness (schizophrenia, bipolar disorder, and other, nonorganic psychoses) in fiscal year 2002 (FY2002) (N=191,625) and from a national random sample of veterans in FY2002 who did not receive serious mental illness diagnoses (N=67,965). Logistic regression was used to evaluate the recorded prevalence and predictors of HIV. HIV diagnoses were recorded for 1.0% of patients with serious mental illness and .5% of patients without serious mental illness. Multivariate analyses indicated that individuals with bipolar disorder were no more likely than those without serious mental illness to have a recorded HIV diagnosis (OR=1.08, CI=.93-1.24), whereas those with other psychoses were more likely to have one (OR=1.18, CI=1.01-1.38). An interaction was observed between schizophrenia and substance use disorder. Compared with patients who had neither schizophrenia nor a substance use disorder, those with schizophrenia without a substance use disorder were less likely to have a recorded HIV diagnosis (OR=.49, CI=.42-.58), whereas those with a substance use disorder were more likely to have a recorded HIV diagnosis (OR=1.22, CI=1.04-1.43). Despite the elevated crude recorded prevalence of HIV, multivariate analyses suggested that HIV-related risk factors underlie the associations between HIV and the serious mental illness diagnoses. For patients with schizophrenia, this study is the first to demonstrate reduced HIV risk in the absence of a substance use disorder.

Impact of Comorbidity on Colorectal Cancer Screening in the Veterans Healthcare System

The quality assessment measure of colorectal cancer screening in the veteran's health system reports the proportion of patients aged 52-80 years who were tested. This approach does little to assess for comorbid illnesses, which might limit the utility of screening. Our aim was to determine the relationship between patient comorbidity and screening by fecal occult blood test in a national sample of veterans. We examined the Veterans Health Administration's national databases (October 2003-February 2005) for a random sample of primary care patients, aged > or = 50 years. The Charlson score, a validated measure of comorbidity burden, was calculated from diagnosis codes by the Deyo method. The association between Charlson score and colorectal cancer screening was assessed with logistic regression. The sample of 77,268 was 97% men; mean age was 67 years. Charlson score distribution was 0, 45%; 1, 24%; 2, 14%; 3, 7%; 4, 4%; 5, 2%; 6, 1%; 7, 0.8%; 8, 0.6%; 9, 0.4%; > or = 10, 1%. Overall there was no consistent significant association between Charlson score and use of fecal occult blood testing except in the sickest 1%. There was a strong and incremental relationship between Charlson score and 1-year mortality. Although there was a strong relationship in the veteran population between the Charlson score and survival, colorectal cancer screening utilization was not impacted by Charlson score. Instead, resources were expended evenly throughout the population, rather than directed toward screening the patients with the most life-years at stake. The quality measure for colorectal cancer screening should be modified to account for patient comorbidity.

Differential Medication Adherence Among Patients With Schizophrenia and Comorbid Diabetes and Hypertension

Global patient characteristics may affect adherence across all medications in a regimen, making medication-specific risk factors for adherence problems less important. Medication adherence was examined among patients with schizophrenia and comorbid physical conditions for consistency across therapeutic classes. A national sample of veterans was selected according to use of medication for schizophrenia, diabetes, and hypertension (N=1,686). Adherence to each medication type was assessed with medication possession ratios (MPRs). Multilevel logistic models were used to study the impact of medication type on adherence, as well as the effect of other medication characteristics (such as the average days of medication supplied per refill), health service use, and patients' sociodemographic characteristics. Adherence was only modestly correlated across types of medication. Information about antipsychotic adherence explained only 13% and 16% of the variance in patients' antihypertensive and hypoglycemic MPRs, respectively. In unadjusted analyses, patients were more likely to have poorer adherence (MPR less than .8) to their antipsychotics (35%) than to their hypoglycemic (29%) or antihypertensive medications (26%) (p<.001). However, when analyses controlled for the average days' supply and other regimen characteristics, hypoglycemic and antihypertensive medications were associated with an increased risk of poor adherence relative to antipsychotics (both adjusted odds ratios=1.5, p<.001). Patients with schizophrenia and comorbid physical conditions demonstrated important differences in adherence across medications in their regimen, reinforcing the importance of medication-specific factors in determining adherence behavior. The lower levels of adherence observed for antipsychotics may be associated with the shorter refill intervals for these medications.

Compensation of Veterans with Psychiatric or Substance Abuse Disorders and Employment and Earnings

Using a national sample of veterans, we examined the relationship between disability income and employment, adjusting for health status and other factors. Veterans Affairs disability income payments had no globally detrimental effect on labor force participation, in that the likelihood of employment was reduced only at payment levels of more than $800 per month. Although unearned income from other sources also did not have a substantial negative effect on labor force participation, veterans who received benefits from the Social Security Administration or welfare payments were less likely to be employed, mostly likely because employment earnings above a certain level in some programs may result in the loss of monetary benefits and health insurance.

GEOGRAPHIC VARIATION ACROSS VETERANS AFFAIRS MEDICAL CENTERS IN THE TREATMENT OF EARLY STAGE PROSTATE CANCER

We investigated geographic variation in the treatment of early stage prostate cancer in a national sample of veterans after widespread adoption of the prostate specific antigen test. Our sample consisted of 16,352 cases from the Veterans Affairs Central Cancer Registry that were diagnosed between January 1997 and December 1999 with stage I or II prostate cancer. We used a 2-stage nested logit model to compare surgery, radiation therapy and noncurative treatment among 4 geographic regions of the United States. Multivariate analysis showed that patients in the West (referent group) had a higher OR of undergoing surgery than radiation compared with the Northeast, South or Midwest (OR 0.77, 95% CI 0.67 to 0.87, OR 0.86, 95% CI 0.76 to 0.98 and OR 0.75, 95% CI 0.64 to 0.87, respectively. Black men, men with lower grade and higher stage tumors, and unmarried men were less likely to undergo curative treatment and less likely to undergo surgery than radiation. Geographic variation persists in patterns of care in men with early stage prostate cancer. However, this variation is limited to the choice between surgery and radiation rather than to the choice between curative and noncurative treatment.

Nonsteroidal antiinflammatory drug use among patients with GI bleeding.

Previous studies have suggested that recommended gastroprotective strategies such as gastroprotective agents (GPAs) and cyclooxygenase (COX) 2 inhibitors may be underutilized among individuals at risk for nonsteroidal antiinflammatory drug (NSAID)-related gastrointestinal (GI) bleeding. To examine the use of traditional NSAIDs, COX-2 inhibitors, and GPAs among patients recently hospitalized for GI bleeding. This was a retrospective cohort study of a national sample of 4338 veterans hospitalized for GI bleeding between January and June 1999. Prescription drug use was examined for 6 months following hospitalization. We examined relationships of subject characteristics (age, race, gender, geographic region, diagnosis of arthritis) to prescription of a high-risk NSAID, defined as a traditional NSAID but no GPA within 60 days before or after the NSAID. Approximately 20% of subjects were prescribed an NSAID or COX-2 inhibitor, but only 5% were prescribed a traditional NSAID with no GPA. In a multivariable analysis, subjects <65 years of age and those with arthritis were more likely to be prescribed a traditional NSAID without a GPA. No other subject characteristics were related to receipt of a high-risk prescription. In a national sample of veterans with a recent hospitalization for GI bleeding, high-risk NSAID prescriptions were uncommon. Underuse of gastroprotective strategies may be more common in patients with less recent GI bleeding-related hospitalization. Strategies to remind physicians and pharmacists to screen for GI risk factors may help to sustain appropriate prescribing and reduce NSAID-related adverse events.

Upper Limb Pain in Anational Sample of Veterans With Paraplegia

Background and Objectives: The purpose of this survey study was to examine the prevalence and intensity of pain and associated patient characteristics in a national sample of veterans with paraplegia. Of particular interest were upper limb (UL) pain conditions, which pose unique challenges to individuals who use a wheelchair for mobility. Because the risk for UL pain conditions appears to increase over time, the associations among age, duration of wheelchair use, and UL pain were evaluated.Methods: A group of 1 ,6 7 5 individuals between the ages of 1 8 and 65 with a lesion between T2 and L2 and a mailing address on file were selected randomly from the Veteran's Affairs Spinal Cord Dysfunction Registry and mailed a survey packet. Of the deliverable packets, -46% were completed and returned.Results: Approximately 81% of the respondents reported at least a minimal Ievei of ongoing unspecified pain and 69'7'o experienced current UL pain. Shoulder pain intensity was most severe du ring the performance of wheelchair-related mobility and transportation activities, suggesting that UL pain may have a significant impact on functional independence. Duration of wheelchair use modestly predicted shoulder pain prevalence and intensity, but age and the interaction between age and duration of wheelchair use did not.Condusion: The data of the present study suggest that the development, persistence, and exacerbation of UL pain conditions in persans with paraplegia aremultidimensional processes. A comprehensive theoretic model is needed to integrate the existing empiric Iiterature in this area.

Use of Medical Services by Veterans With Mental Disorders

This study examined timeliness, access, and intensity of outpatient medical service use in a national sample of veterans with comorbid medical disorders discharged from Veterans Affairs (VA) psychiatric units (N = 44,533). The factors that predicted decreased use of medical services included diagnosis of schizophrenia, posttraumatic stress disorder, and substance abuse. The factors associated with increased use of medical services included proximity to a VA outpatient clinic, receipt of VA compensation payments, discharge from a facility with greater resources devoted to medical-surgical care, and prompt outpatient mental health follow-up. Better integration of medical and psychiatric services may help improve access to medical care for the severely mentally ill.