Veterans Health Administration Use 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.

Posttraumatic stress disorder, Veterans Health Administration use, and care-seeking among recent-era U.S. veterans.

The current study investigated the associations among probable posttraumatic stress disorder (PTSD), recent Veterans Health Administration (VHA) health care use, and care-seeking for PTSD in U.S. military veterans. Analyses were conducted among 19,691 active duty military personnel enrolled in the Millennium Cohort Study who separated from the military between 2000 and 2012 and were weighted to the 1,130,103 active duty personnel who separated across this time period. VHA utilization was identified from electronic medical records in the year before survey completion, and PTSD care-seeking and PTSD symptoms were assessed through self-report on the 2014-2016 survey; thus, the observation period regarding care-seeking and VHA use encompassed 2013-2016. Veterans with probable PTSD were more likely to use VHA services than those without probable PTSD, aOR = 1.12, 95% CI [1.01, 1.24], although the strongest association with recent VHA use was a depression diagnosis, aOR = 2.47, 95% CI [2.26, 2.70]. Among veterans with probable PTSD, the strongest predictor of care-seeking was recent VHA use compared to community care, aOR = 4.01, 95% CI [3.40, 4.74); reporting a diagnosis of depression was the second strongest predictor of PTSD care-seeking, OR = 2.99, 95% CI [2.53, 3.54]. However, the absolute number of veterans with probable PTSD who were not seeking care was approximately equivalent between veterans using VHA services and those not using VHA services. Additionally, certain groups were identified as being at risk of not seeking care, namely Air Force veterans and veterans with high physical and mental functioning despite substantial PTSD symptoms.

Differences in use of Veterans Health Administration and non-Veterans Health Administration hospitals by rural and urban Veterans after access expansions.

To examine changes in rural and urban Veterans' utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization. Using repeated cross-sectional data of VHA enrollees' hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans' probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans' travel distances to hospitals. Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans' probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals. Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans' use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

Understanding Veterans' intimate partner violence use and patterns of healthcare utilization.

To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. We assessed associations between past-year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non-VA services using chi-square tests and logistic regression. Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post-traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non-VA providers. Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

Development and validation of a standardized blood culture contamination definition and metric dashboard for a large health care system.

Blood culture contamination is a major problem in health care, with significant impacts on both patient safety and cost. Initiatives to reduce blood culture contamination require a reliable, consistent metric to track the success of interventions. The objective of our project was to establish a standardized definition of blood culture contamination suitable for use in a Veterans Health Administration (VHA) national data query, then to validate this definition and query. A secondary objective was to construct a national VHA data dashboard to display the data from this query that could be used in VHA quality improvement projects aimed at reducing blood culture contamination. A VHA microbiology expert work group was formed to generate a standardized definition and oversee the validation studies. The standardized definition was used to generate data for calendar year 2021 using a Structured Query Language data query. Twelve VHA hospital microbiology laboratories compared the data from the query against their own locally derived contamination data and recorded those data in a data collection worksheet that all sites used. Data were collated and presented to the work group. More than 50,000 blood culture accessions were in the validation data set, with more than 1,200 contamination events. The overall blood culture contamination rate for the 12 facilities participating was 2.56% with local definitions and data and 2.43% with the standardized definitions and data query. The main differences noted between the 2 data sets were deemed to be issues in local definitions. The query and definition were then converted into a national data dashboard that all VHA facilities can now access. A standardized definition for blood culture contamination and a national data query were validated for enterprise-wide VHA use. To our knowledge, this represents the first reported standardized, validated, and automated approach for calculating and tracking blood culture contamination. This tool will be key in quality initiatives aimed at reducing contamination events in VHA.

Racial, ethnic, and sex differences in psychiatric diagnosis, mental health sequelae, and VHA service utilization among justice-involved veterans.

Intervening in the cycle of symptom exacerbation and recidivism among justice-involved veterans is critical given elevated rates of psychiatric diagnoses and mental health sequelae. To responsively and effectively address justice-involved veterans' needs, it is essential to examine distinct groups who are at heightened risk (e.g., marginalized communities). Although racial and ethnic disparities within the justice system are well established, veteran-focused research remains limited. We hypothesized that significant differences exist in service utilization, psychiatric diagnoses, and mental health sequelae among Black, Indigenous, and people of color (BIPOC) and White/non-Hispanic justice-involved veterans, for both male and female cohorts. We examined a national data set of veterans accessing U.S. Department of Veterans Affairs (VA) justice-related services (i.e., justice-involved veterans) between 2005 and 2018 (N = 183,880; nBIPOC = 73,863, nWhite = 110,017) to elucidate racial and ethnic differences across clinical characteristics documented in the VA electronic medical record. Using linear and logistic analyses, we analyzed male (n = 173,487) and female (n = 10,393) justice-involved veterans separately to capture intersectionality. In general, BIPOC justice-involved veterans were more likely than White/non-Hispanic justice-involved veterans to be diagnosed with schizophrenia and other psychotic disorders and to use homeless services, p < .001. They were less likely to be diagnosed with mood, anxiety, personality, and opioid use disorders, p < .01. Separate examinations of Black and Hispanic justice-involved veterans, compared with their White/non-Hispanic counterparts, demonstrated some divergent trends (e.g., frequency of use of Veterans Health Administration [VHA] services). Our findings also revealed nuanced sex-related differences in terms of service use and diagnoses. Descriptive characteristics for each racial and ethnic category are reported. These findings provide support for race and ethnicity as a key social factor of health associated with distinct psychiatric diagnoses and mental health sequelae among justice-involved veterans. We discuss practice and policy implications, including how to adapt existing VHA programming and practices to meet the needs of BIPOC justice-involved veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Use of Veterans Health Administration Structured Data to Identify Patients Eligible for Lung Cancer Screening.

Lung cancer screening (LCS) uptake is low. Assessing patients' cigarette pack-years and years since quitting is challenging given the lack of documentation in structured electronic health record data. We used a convenience sample of patients with a chest CT scan in the Veterans Health Administration. We abstracted data on cigarette use from electronic health record notes to determine LCS eligibility based on the 2021 U.S. Preventive Services Task Force age and cigarette use eligibility criteria. We used these data as the "ground truth" of LCS eligibility to compare them with structured data regarding tobacco use and a COPD diagnosis. We calculated sensitivity and specificity as well as fast-and-frugal decision trees. For 50-80-year-old veterans identified as former or current tobacco users, we obtained 94% sensitivity and 47% specificity. For 50-80-year-old veterans identified as current tobacco users, we obtained 59% sensitivity and 79% specificity. Our fast-and-frugal decision tree that included a COPD diagnosis had a sensitivity of 69% and a specificity of 60%. These results can help health care systems make their LCS outreach efforts more efficient and give administrators and researchers a simple method to estimate their number of possibly eligible patients.

Suicide risk following a new cancer diagnosis among Veterans in Veterans Health Administration care.

Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk. Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012-2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis. A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR]=1.47, 95% CI: 1.33-1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR=6.01, 95% CI: 3.73-9.68), and other significant subtypes included head and neck (aHR=3.55, 95% CI: 2.74-4.62) and lung cancer (aHR=2.35, 95% CI: 1.85-3.00). Cancer stages 3 (aHR=2.36, 95% CI: 1.80-3.11) and 4 (aHR=3.53, 95% CI: 2.81-4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3-6- and 6-12-month periods following diagnosis. Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer.

Receipt of clinician-delivered firearm safety counseling among U.S. Veterans: Results from a 2019 national survey.

Seventy percent of suicides among U.S. veterans are due to firearm injury. Because discussions about firearm access are an important component of evidence-based suicide prevention programs, we sought to quantify the proportion of U.S. veterans who have discussed firearm safety with a healthcare provider. Data come from a probability-based, nationally representative online survey of U.S. adults living in households with firearms in 2019 (response 65%). In this study, we include only self-identified veteran firearm owners. Respondents were asked, "Has a physician or other healthcare practitioner ever spoken to you about firearm safety?" Analyses were stratified by self-reported use of Veterans Health Administration (VHA) healthcare services. Overall, 31.5% (95% CI 27.5-35.8) reported using VHA services and 9.2% (95% CI 6.8-12.3) reported that a clinician had ever spoken with them about firearm safety (14.3% among VHA users, 6.8% among non-users). Of those who reported a discussion, nearly three quarters reported it was with an outpatient primary care physician or medical specialist. A large majority of veteran firearm owners have not had, or do not recall having had, a firearm safety discussion with a clinician, suggesting that additional efforts to facilitate such discussions in the VHA and elsewhere are needed.

A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality

BackgroundHomeless Veterans are at substantially elevated risk for suicide mortality; however, understanding of drivers of suicide in this population remains limited. MethodBuilding upon prior work, we conducted a retrospective chart review, comprised of a latent class analysis of 724,752 Veterans with use of Veterans Health Administration (VHA) homeless services 2005–2018. ResultsA five-model class membership solution was identified. Among these classes, risk for suicide mortality was greatest among Veterans with the highest psychiatric burden and high VHA service use. Those experiencing moderate psychiatric burden or primarily experiencing substance use disorders also experienced elevated risk for suicide mortality relative to those with low burden and service use. LimitationsModels were specific to Veterans accessing VHA homeless services and may not generalize to those not using such services outside VHA care. ConclusionsContinued research and programing remain necessary to determine how to address mental health conditions and engage homeless Veterans in services to facilitate suicide prevention.

Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017.

BackgroundHome telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade.ObjectiveTo describe trends in use of VHA’s HT program from 2010 through 2017 and correlates of length of enrollment in HT services.DesignRetrospective observational cohort study.ParticipantsPatients enrolled in HT between January 1, 2010 and December 31, 2017.Main MeasuresWe described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment.Key ResultsThe total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index.ConclusionsAcross 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

BackgroundConsensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.ObjectiveTo examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.DesignCross-sectional nationally representative study.ParticipantsUS military veterans (N = 2,836).Main MeasuresIn the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).Key ResultsChronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07–2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12–2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12–3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35–6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69–10.87).ConclusionsAmong veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Veteran drug overdose mortality, 2010–2019

BackgroundPrior work documents that Veteran drug overdose mortality increased from 2010 to 2016. The present study assessed trends from 2010 to 2019, by drug type and recent receipt of Veterans Health Administration (VHA) services, and compared rates for Veteran and non-Veteran US adults. MethodsThis retrospective cross-sectional study used data from Veterans Affairs (VA) medical records, the VA/Department of Defense Mortality Data Repository, and CDC WONDER. Trends were compared using Joinpoint regression. ResultsFrom 2010–2019, age-adjusted overdose mortality rates increased 53.2% among Veterans and 79.0% among non-Veterans. Age-adjusted rates of overdose mortality among Veterans rose from 19.8/100,000 in 2010 to 32.6/100,000 in 2017, before falling to 30.3/100,000 in 2019. Despite the decrease from 2017 to 2019 in overall overdose mortality, rates of overdose deaths involving synthetic opioids other than methadone and involving psychostimulants continued to increase through 2019. In 2019, overdose mortality was lower for male Veterans than male non-Veterans (standardized rate ratio (SRR) = 0.81, 95% confidence interval (CI): 0.77–0.84). Among male Veterans, rates were higher in all years for those with recent VHA use than those without (2019: SRR=1.69, 95% CI: 1.56–1.83). From 2010–2019, overdose mortality rates increased faster among female Veterans without VHA use than those with VHA use. ConclusionsFrom 2015 onward, Veteran men experienced lower age-adjusted overdose rates than non-Veteran men. In all years, overdose rates were higher among male Veterans with recent VHA use than those without recent use. While overall rates of Veteran overdose deaths declined from 2017 to 2019, rates involving psychostimulants and synthetic opioids continued to rise.

Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care.

There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.

Indicators of Elder Mistreatment: Correlates among Veterans Receiving Care in the Veterans Health Administration

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.

Institutional betrayal and help-seeking among women survivors of military sexual trauma.

The current study examined if IB was associated with women veterans' willingness to seek VHA and non-VHA mental health and medical care, prior use of VHA care, past year use of VHA care, and use of VHA and non-VHA MST-related care. Participants were 242 women veterans who screened positive for MST and completed self-report measures of IB and willingness to seek VHA and non-VHA mental health and medical care. Use of VHA care was assessed through VA Corporate Data Warehouse data. IB was associated with lower willingness to use VHA medical care and higher willingness to use non-VHA mental health care. Although IB was not significantly associated with prior use of VHA care, participants who reported more IB were more likely to have used VHA care in the past year and to have used both VHA and non-VHA MST-related care. These findings illuminate the relationship between the institutional response to MST with women's help-seeking willingness and use. Addressing IB may be important for increasing women MST survivors' willingness to use VHA medical care. Additionally, as IB was associated with greater willingness to use non-VHA mental health care, non-VHA institutions and providers should be prepared to serve women veterans who have experienced MST-related IB. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Suicide risk following a new cancer diagnosis among veterans in Veterans Health Administration care.

12130 Background: Patients diagnosed with cancer are at an increased risk of adverse mental health outcomes including suicidal behavior. Suicide rates among Veterans are 50 percent greater than for non-Veteran US adults. To inform Veterans Affairs (VA) suicide prevention initiatives, it is important to understand associations between cancer and suicide risk among Veterans receiving VA healthcare from the Veterans Health Administration (VHA). Study aims were to assess associations between new cancer diagnoses and suicide among Veterans in VHA care to identify high risk diagnostic subgroups and risk-periods. Methods: We used a cohort study design, identifying 4,926,373 Veterans with VHA use in 2011 and either 2012 or 2013 and without a VHA cancer diagnosis in 2011. Incident cancer diagnoses, assessed between first VHA use in 2012-2013 and 12/31/2018, were characterized by subtype and stage using the VHA Oncology Raw Data. Data from the VA/Department of Defense Mortality Data Repository identified date and cause of death. Cox proportional hazards regression, accounting for time-varying cancer diagnosis, was used to evaluate associations between a new cancer diagnosis and suicide risk. An initial model adjusted for VHA regional network and patient age and sex. Cancer subtypes with significant associations with suicide were further assessed using a model that also adjusted for suicide attempts and mental health, tobacco use disorder, and other substance use disorder diagnoses in the prior year. Crude suicide rates following a new cancer diagnoses were calculated among Veterans with new diagnoses, 2012-2018 (N = 240,410). Rates were assessed up to 84 months following diagnosis. Results: On average, Veteran VHA users were followed for 6.0 years after their first VHA use in 2012-2013 and for 2.7 years following a new cancer diagnosis. Receipt of a new cancer diagnosis corresponded to a 43% (Adjusted Hazard Ratio [AHR] = 1.43, 95% CI: 1.29, 1.58) higher suicide risk, adjusting for covariates. The cancer subtype associated with the highest suicide risk was esophageal cancer (AHR = 5.93, 95% CI: 4.05, 10.51) and other significant subtypes included head and neck (AHR = 3.44, 95% CI: 2.65, 4.46) and lung cancer (AHR = 2.28, 95% CI: 1.79, 2.90). Cancer stages 3 (AHR = 2.29, 95% CI: 1.75, 3.01) and 4 (AHR = 3.45, 95% CI: 2.75, 4.34) at diagnosis were also positively associated with suicide risk. Suicide rates were highest in the first three months following a diagnosis (Rate = 128.3 per 100,000 person-years, 95% CI: 100.4, 161.6) and remained elevated through the first 12 months. Conclusions: Among Veteran VHA users, suicide risk was elevated following a new cancer diagnosis and was especially high in the initial 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer, particularly among those diagnosed with esophageal, head and neck, or lung cancer or at stages 3 or 4.

Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice.

Background:The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers.Objectives:The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider.Research Design:This was a retrospective, observational over fiscal years (FY) 2015–2018.Subjects:Veterans receiving primary care services paid for by the VA.Measures:Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year.Results:There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care.Conclusion:As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans’ use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans’ health care needs are met.

Impact of Attitudes and Rurality on Veterans' Use of Veterans Health Administration Mental Health Services.

Veterans, especially those residing in rural areas, continue to underutilize mental health care. This longitudinal study assessed attitudes relevant to seeking mental health care services from the Veterans Health Administration (VHA) over 12 months, adjusting for residence. A questionnaire addressing attitudes, sociodemographic factors, residence, place identity, perceived health status and needs, and structural barriers was administered by telephone to 752 veterans with previous VHA service use. Service use data were obtained from a VHA database. In adjusted models, four attitudes were significantly associated with underuse of VHA mental health care (no use vs. any use; no use vs. nonsustained use vs. sustained use). Higher levels of mistrust of others (adjusted odds ratio [AOR]=1.06, p=0.046), emotional stoicism (AOR=1.08, p=0.003), belief in the self-resolving nature of mental health problems (AOR=1.91, p=0.015), and belief in the efficacy of religious counseling for such problems (AOR=1.09, p=0.022) were associated with no subsequent service use versus any use. Place identity (suburban), older age, and greater need were associated with greater odds of VHA use. For the comparison of no use versus sustained use, women had lower odds of no use (AOR=0.49, p<0.001); similarly, women had lower odds of nonsustained use versus sustained use (AOR=0.45, p<0.001). The association of potentially modifiable attitudes with underuse of VHA mental health services suggests that attitudes offer useful targets for efforts to increase mental health care use. That these attitudes were influential regardless of residence suggests that programs addressing attitudinal barriers can be broadly targeted.