Native Veterans Research Articles

Suicide Rates by Age and Time Among American Indian and Alaskan Native Veterans

Objective: Although recent work has highlighted high rates of suicide among American Indian and Alaska Native individuals who served in the US military, to date, a comprehensive evaluation of age-specific suicide rates, over time, has yet to be conducted. Methods: Population-based retrospective cohort study. Average annual suicide rates (2005–2020) were computed. The cohort included 207,955 Native Veterans who were alive as of January 1, 2005, and separated from military service on or before December 31, 2020. Suicide was identified via National Death Index codes. Results: Between 2005 and 2020, average annual, age-specific suicide rates among Native Veterans ranged from 16.32/100,000 (55+ y) to 64.49/100,000 (18–34 y). Compared with other age-related cohorts, the rate among those in the youngest age cohort (18–34y) was the highest between 2005 and 2018. The 2019–2020 average annual rate for 18- to 34-year-olds (41.86/100,000) dropped below that of the middle-aged cohort (35–45 y; 44.66/100,000). Across all age cohorts, firearms were the most used method of suicide [57.2% (18–34 and 35–54 y) to 66.17% (55+y)]; however, a notable percentage of Veterans died by suffocation, 16.54% (55 y and older), 26.71% (35–54 y), and 33.21% (18–34 y). Conclusions: Findings highlight differences in suicide rates by age groups overtime for Native Veterans irrespective of Veterans Health Administration use and across service eras, as well as means of suicide, which also differed across groups. Increased efforts are needed to identify culturally and age-relevant intervention strategies, as well as factors associated with risk, to reduce deaths among Native Veterans.

Factors Associated With Influenza Vaccination in a National Veteran Cohort

IntroductionOnly 53% of American adults receive influenza vaccination, and disparities in vaccination exist amongst particular racial and ethnic groups. This study determines how race, ethnicity, sex, and rurality are associated with influenza vaccination adherence in a national Veteran Health Affairs Administration (VHA) cohort. MethodsWe examined differences in documented influenza vaccinations for the 2019-2020 influenza season among VHA patients in a retrospective cohort study using VHA administrative electronic health record data. We used logistic regression to model receipt of influenza vaccination in association with race, ethnicity, sex, and rurality while controlling for clinical diagnoses, demographics, and ambulatory care utilization. We also stratified the models by sex and rurality. ResultsAmong 5,943,918 veterans, 48.6% received influenza vaccination. Unadjusted comparisons showed those who were vaccinated were more likely to be white, male sex, and older. Similar proportions of unvaccinated and unvaccinated veterans were from rural settings. In adjusted models, Black race was most strongly associated with decreased vaccination (AOR=0.69, [0.69-0.70]), and American Indian/Alaskan Native race also had reduced odds of vaccination (AOR=0.94 [0.92-0.95]) compared to White race. Female veterans had increased odds of vaccination (AOR=1.20; [1.19-1.20]) compared to men. Rurality (AOR=0.97 [0.96-0.97]) was associated with a small decreased odds of vaccination compared to urban. In stratified models, Black veterans were less likely to receive influenza vaccination regardless of sex and rurality compared to White veterans. American Indian/Alaska Native female veterans had equal odds of vaccination as compared to White female veterans, while American Indian/Alaska Native male veterans had reduced odds of vaccination compared to White male veterans. ConclusionsDuring the 2019-2020 influenza season, Black and American Indian/Alaskan Native veterans had lower odds of vaccination. Despite the VHA's universal approach to healthcare, racial disparities still exist in preventive care.

Trends in Racial and Ethnic Disparities in Early Glycemic Control Among Veterans Receiving Care in the Veterans Health Administration, 2008-2019.

Racial and ethnic disparities in glycemic control among non-Hispanic Black (NHB) and non-Hispanic White (NHW) veterans with type 2 diabetes (T2D) have been reported. This study examined trends in early glycemic control by race and ethnicity to understand how disparities soon after T2D diagnosis have changed between 2008 and 2019 among cohorts of U.S. veterans with newly diagnosed T2D. We estimated the annual percentage of early glycemic control(average A1C <7%) in the first 5 years after diagnosis among 837,023 veterans (95% male) with newly diagnosed T2D in primary care. We compared early glycemic controlby racial and ethnic group among cohorts defined by diagnosis year (2008-2010, 2011-2013, 2014-2016, and 2017-2018) using mixed-effects models with random intercepts. We estimated odds ratios of early glycemic controlcomparing racial and ethnic groups with NHW, adjusting for age, sex, and years since diagnosis. The average annual percentage of veterans who achieved early glycemic controlduring follow-up was 73%, 72%, 72%, and 76% across the four cohorts, respectively. All racial and ethnic groups were less likely to achieve early glycemic controlcompared with NHW veterans in the 2008-2010 cohort. In later cohorts, NHB and Hispanic veterans were more likely to achieve early glycemic control; however, Hispanic veterans were also more likely to have an A1C ≥9% within 5 years in all cohorts. Early glycemic controldisparities for non-Hispanic Asian, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native veterans persisted in cohorts until the 2017-2018 cohort. Overall early glycemic controltrends among veterans with newly diagnosed T2D have been stable since 2008, but trends differed by racial and ethnic groups and disparities in very poor glycemic control were still observed. Efforts should continue to minimize disparities among racial and ethnic groups.

Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development.

American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care. Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US. Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality. Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

Tribal Perspectives on Patient Navigation for Rural Native Veterans Using Veteran Health Administration Services.

American Indian and Alaska Native (Native) Veterans enrolled in theU.S. Department of Veterans Affairs(VA) benefits program are far less likely to access health care compared to other racial/ethnic groups, in part driven by challenges posed by often distant, complex, and culturally unresponsive health care that does not easily interface with the Indian Health Service (IHS) and local Tribal Health Care. To address this disparity, in 2020 the Veteran's Health Administration's (VHA) Office of Rural Health (ORH) initiated the development of a patient navigation program designed specifically for rural Native Veterans. There are no navigation programs for rural Native Veterans to guide development of such a program. Hence, the project team sought perspectives from rural Native Veterans, their families, and community advocates, (n = 34), via video and phone interviews about the role and functions of a Veteran patient navigator and personal characteristics best be suited for such a position. Participants believed a navigator program would be useful in assisting rural Native Veterans to access VHA care. They emphasized the importance of empathy, support, knowledge of local culture, and of Veteran experience within tribal communities, adeptness with VHA systems, and personnel consistency. These insights are critical to create a program capable of increasing rural Native Veteran access to VHA services.

The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study.

The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person. The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. DERR1-10.2196/51324.

Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans

American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown. To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity. In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined. At least 1 outpatient MH encounter during the study period. The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models. Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001). In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

Opioid and High-Risk Prescribing Among Racial and Ethnic Minority Veterans

The purpose of this study is to compare opioid prescribing and high-risk prescribing by race and ethnicity in a national cohort of U.S. veterans. A cross-sectional analysis of veteran characteristics and healthcare use was performed on electronic health record data for 2018 Veterans Health Administration users and enrollees in 2022. Overall, 14.8% received an opioid prescription. The adjusted odds of being prescribed an opioid were lower for all race/ethnicity groups than for non-Hispanic White veterans, except for non-Hispanic multiracial (AOR=1.03; 95% CI=0.999, 1.05) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=1.03, 1.09) veterans. The odds of any day of overlapping opioid prescriptions (i.e., opioid overlap) were lower for all race/ethnicity groups than for the non-Hispanic White group, except for the non-Hispanic American Indian/Alaska Native group (AOR=1.01; 95% CI=0.96, 1.07). Similarly, all race/ethnicity groups had lower odds of any day of daily dose >120 morphine milligram equivalents than the non-Hispanic White group, except for the non-Hispanic multiracial (AOR=0.96; 95% CI=0.87, 1.07) and non-Hispanic American Indian/Alaska Native (AOR=1.06; 95% CI=0.96, 1.17) groups. Non-Hispanic Asian veterans had the lowest odds for any day of opioid overlap (AOR=0.54; 95% CI=0.50, 0.57) and daily dose >120 morphine milligram equivalents (AOR=0.43; 95% CI=0.36, 0.52). For any day of opioid-benzodiazepine overlap, all races/ethnicities had lower odds than non-Hispanic White. Non-Hispanic Black/African American (AOR=0.71; 95% CI=0.70, 0.72) and non-Hispanic Asian (AOR=0.73; 95% CI=0.68, 0.77) veterans had the lowest odds of any day of opioid-benzodiazepine overlap. Non-Hispanic White and non-Hispanic American Indian/Alaska Native veterans had the greatest likelihood to receive an opioid prescription. When an opioid was prescribed, high-risk prescribing was more common in White and American Indian/Alaska Native veterans than in all other racial/ethnic groups. As the nation's largest integrated healthcare system, the Veterans Health Administration can develop and test interventions to achieve health equity for patients experiencing pain.

Culturally Centered Implementation of Video Telehealth for Rural Native Veterans.

Introduction: Native American Veterans are the most rural and experience heightened risk for mental health (MH) challenges while facing significant health care inequities and access barriers. Rural Native Veterans (RNVs) have experienced historical loss and racial discrimination, contributing to mistrust of Veterans Health Administration (VHA) and other Federal systems. Telemedicine, including video telehealth (VTH), can improve access to MH care for RNVs by addressing barriers. Understanding the cultural context and existing community resources can improve engagement and implementation efforts with RNVs. Objective: This article describes a model of culturally centered MH care and a flexible implementation approach, Personalized Implementation of Virtual Treatments for Rural Native Veterans (PIVOT-RNV), used to disseminate the model. Methods: Participants included four VHA sites serving large RNV populations where PIVOT-RNV was applied to expand the availability of virtual solutions, including VTH, for RNVs. A mixed methods formative evaluation tracked VTH utilization and used provider and RNV feedback to inform iterative process improvements. Results: Where PIVOT-RNV was used, number of providers using VTH with RNVs, number of unique RNVs receiving MH care through VTH, and number of VTH encounters with RNVs grew annually. Provider and RNV feedback highlighted the importance of addressing the unique barriers and cultural context of RNVs. Conclusions: PIVOT-RNV demonstrates promise for improving implementation of virtual treatments and access to MH care for RNVs. The integration of implementation science within a cultural safety framework helps address specific barriers to adoption of virtual treatments for RNVs. Next steps include expanding PIVOT-RNV efforts at additional sites.

A scoping review of veteran suicide prevention programs in Native American communities and in the general population.

Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Variation in initial and continued use of primary, mental health, and specialty video care among Veterans.

To identify which Veteran populations are routinely accessing video-based care. National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021. This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021. Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study. Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations. Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.

American Indian and Alaska Native veterans in the Indian Health Service: Health status, utilization, and cost.

PurposeMany rural American Indian and Alaska Native (AIAN) veterans receive care from the Indian Health Service (IHS). United States Department of Veterans Affairs (VA) has reimbursement agreements with some IHS facilities and tribal programs and seeks to expand community partnerships in tribal areas, but details of how AIAN veterans use IHS are unknown. We aimed to assess the health status, service utilization patterns, and cost of care of veterans who use IHS.MethodsWe used comprehensive and integrated IHS data to compare health status, health service utilization and treatment cost of veterans (n = 12,242) to a matched sample of non-veterans (n = 12,242). We employed logistic, linear, or negative binomial regressions as appropriate, by sex and overall.FindingsCompared to non-veterans, veterans had lower odds of having hypertension, renal disease, all-cause dementia, and alcohol or drug use disorders, but had similar burden of other conditions. In service utilization, veterans had lower hospital inpatient days; patterns were mixed across outpatient services. Unadjusted treatment costs for veterans and non-veterans were $3,923 and $4,145, respectively; veteran adjusted treatment costs were statistically lower. Differences in significance by sex were found for health conditions and service use.ConclusionsAIAN veterans, compared to AIAN non-veterans, were not less healthy, nor did they require more intensive or more costly care under IHS. Our results indicate the viability and importance of expanding IHS-VA partnerships in community care.

Suicide Among American Indian and Alaska Native Veterans Who Use Veterans Health Administration Care: 2004-2018.

Background:American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population.Methods:We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed.Results:Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1–47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014–2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18–39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%).Conclusions:Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.

The Role of Community-Level Factors on Disparities in COVID-19 Infection Among American Indian/Alaska Native Veterans.

ObjectivesAmerican Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reservations.MethodsUsing Veteran Health Administration’s (VHA) national database of VHA users evaluated for COVID-19 infection (3/1/2020–8/25/2020), we examined whether census tract neighborhood characteristics (percent households overcrowded, without complete plumbing, without kitchen plumbing, and neighborhood socioeconomic status [n-SES]) mediated racial disparities in COVID-19 infection, using inverse odds-weighted logistic models controlling for individual-level characteristics. Using moderated mediation analyses, we assessed whether neighborhood mediating effects on disparities differed for those residing in counties containing/near federally recognized tribal lands (i.e., Contract Health Service Delivery Area [CHSDA] counties) versus not.ResultsThe percent of households without complete plumbing, percent without kitchen plumbing, and n-SES partially mediated AI/AN-White-non-Hispanic COVID-19 infection disparities (accounting for 17–35% of disparity) to a similar extent in CHSDA and non-CHSDA counties. The percent of households without kitchen plumbing had stronger mediating effects for CHSDA than non-CHSDA residents.ConclusionsNeighborhood-level social determinants of health may contribute to the disproportionate COVID-19 infection burden on AI/ANs; differences are exacerbated among AI/ANs living near reservations.

Consistent Honor, Persistent Disadvantage: American Indian and Alaska Native Veteran Health in the National Survey of Veterans.

Objective: To examine self-rated health and activities of daily living (ADLs) limitations among American Indian and Alaska Native (AI/AN) veterans relative to white veterans. Methods: We use the 2010 National Survey of Veterans and limit the sample to veterans who identify as AI/AN or non-Hispanic white. We calculated descriptive statistics, confidence intervals, and used logistic regression. Results: AI/AN veterans are younger, have lower levels of income, and have higher levels of exposure to combat and environmental hazards compared to white veterans. We found that AI/AN veterans are significantly more likely to report fair/poor health controlling for socioeconomic status and experience an ADL controlling for age, health behaviors, socioeconomic status, and military factors. Discussion: The results indicate that AI/AN veterans are a disadvantaged population in terms of their health and disability compared to white veterans. AI/AN veterans may require additional support from family members and/or Veteran Affairs to address ADLs.

Suicide-related behaviors among American Indian and Alaska Native Veterans: A population-based analysis

ABSTRACT American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010–2012) and National Survey on Drug Use and Health (NSDUH, 2010–2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14–6.31; BRFSS: OR = 2.66, 95% CI 0.96–7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

Rural and Urban American Indian and Alaska Native Veteran Health Disparities: a Population-Based Study.

The health service ecology varies considerably across urban-rural divides for American Indian and Alaska Native (AIAN) veterans, which may place rural AIAN veterans at high risk for poor health outcomes. Using the Behavioral Risk Factor Surveillance System 2011 and 2012 data for its detailed race information, we employed adjusted multinomial logistical regression analyses to estimate differences in health outcomes among rural AIAN veterans (n = 1500) and urban AIAN veterans (n = 1567). We used rural White (n = 32,316) and urban White (n = 59,849) veteran samples as comparators. No statistically significant differences between urban and rural AIAN veterans' health outcomes were found. Urban AIAN veterans were 72% more likely to report financial barriers to care compared with urban White veterans (P = .002); no other healthcare access differences were found. Compared with their White veteran counterparts, both urban and rural AIAN veterans were significantly more likely to report poorer physical and mental health across an array of outcomes. Overall, rural and urban AIAN veterans' health outcomes were similar, but both groups suffered compromised health compared with that of both rural and urban White veterans. The findings identified key areas for improving and innovating care for both rural and urban AIAN veterans.

Outcomes and Lessons Learned from the Tribal Veterans RepresentativeProgram: A Model for System Engagement.

American Indian and Alaska Native Veterans are more rural than Veterans of any other race or ethnicity and face significant barriers to accessing care. Since 2001, the Tribal Veterans Representative (TVR) Program, a partnership between the U.S.Department of Veterans Affairs (VA) and tribal nations, has trained liaisons from tribal communities to facilitate access to VA benefits and services. We delineate the TVR program model alongside supporting data. We reviewed TVR training materials and program evaluations to identify components of the program essential for increasing access to VA services and benefits. We then report a quantitative assessment of benefits attained in one tribal community. The TVR model is characterized by the exchange of two sets of knowledge and resources-'institutional' and 'community'-during a co-sponsored educational program aiming to train community liaisons about the institution. The institution leads the program's content; the community's traditions inform its process. Following the program, liaisons use support networks comprising trainers, trainees and local organizations to teach other community members to access health care and benefits. In the evaluation community, one liaison has facilitated access for hundreds of Veterans, with financial compensation exceeding $400,000 annually. The TVR program has begun to demonstrate its utility for other rural populations, though further formal evaluation is recommended. Compared with similar models to increase rural populations' access to health care and benefits, the long-term support networks from the TVR model may be most useful when the institution must build trust and engage with the target population.

Methodology for Evaluating Models of Telemental Health Delivery Against Population and Healthcare System Needs: Application to Telemental Healthcare for Rural Native Veterans.

Background: Rural American Indian and Alaska Native (AI/AN) Veterans face exceptional barriers to receiving quality mental healthcare. We aimed to identify models of in-person and telemental health service delivery with promise for adaptation and wide dissemination to rural AI/AN Veterans. Methods: Our method for matching specific populations with models of care includes (1) selecting frameworks that represent the healthcare organization's goals, (2) identifying relevant service delivery models for the target population(s), (3) assessing models against the selected frameworks, and (4) summarizing findings across models. We applied this approach to rural AI/AN Veteran populations. Results: Searches identified 13 current models of service delivery for rural AI/AN Veteran, rural AI/AN, and general rural Veteran populations. These models were assessed against four frameworks-the U.S. Department of Veterans Affairs' Office of Rural Health's Promising Practices, Veterans Health Administration's Guide to Mental Health Services, the Institute for Healthcare Improvement's Triple Aim Framework, and the American Indian Telemental Health Clinic framework. Discussion: The one model used for service delivery for rural AI/AN Veterans increases access and is patient-centered but lacks operational feasibility. Models for rural AI/ANs also increase access and are patient-centered but generally lack effectiveness evaluations. Models for rural Veterans demonstrate beneficial effects on mental health outcomes but do not emphasize cultural adaptations to diverse populations. Conclusions: Our approach to selecting models of service delivery considers the needs of operational partners as well as target populations and emphasizes large-scale implementation alongside effectiveness. Pending further testing, this approach holds promise for wider application.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map.

Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group. From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength). Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.