Non-white Veterans Research Articles

Alcohol-Related Problems As Moderators of PTSD Symptom Change During Use of a Web-Based Intervention for Hazardous Drinking and PTSD.

Alcohol-related problems (e.g., physical, interpersonal, intrapersonal, impulse control, social responsibility) can have an impact on posttraumatic stress disorder (PTSD) symptoms during treatment. Evidence-based online self-help tools exist to target alcohol use and related problems and co-occurring PTSD symptoms. It is unknown to what degree individuals with varying alcohol-related problems respond differently to web-based interventions for hazardous alcohol use and PTSD. The current study evaluated specific alcohol-related problems as potential moderators of PTSD symptom changes during the VetChange online intervention while controlling for average daily alcohol use, gender, race, and age. We conducted a secondary analysis of a randomized controlled trial that included 600 post-9/11 veterans (518 men and 82 women). Mixed-effects regression models of alcohol-related problems on PTSD severity scores over time were performed separately in an initial intervention group (IIG; n = 404) and a delayed intervention group (DIG; n = 196) that was used as a comparison condition. Interpersonal problems emerged as a moderator of PTSD symptom changes in IIG such that veterans endorsing greater interpersonal problems demonstrated larger reductions in PTSD symptoms throughout VetChange. There were no significant moderation effects in DIG. Non-White veterans reported significantly higher PTSD symptoms during VetChange. Post hoc analyses indicated that veterans with higher interpersonal problems were more likely to engage in online intervention content focused on identifying high-risk drinking situations and coping with symptoms. Findings imply that veterans reporting alcohol-related interpersonal problems may benefit the most from, and be more motivated to use, online interventions for hazardous alcohol use and PTSD symptoms.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling Among Low-Income U.S. Veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) Study.

This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures of mental illness and substance use, functionality, homelessness, in a nationally representative sample of U.S. military veterans. Data were analyzed from 781 veterans who participated National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study conducted in 2021. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions analyses were conducted to examine unadjusted and adjusted associations between gambling group status and sociodemographic, psychiatric, substance use, functioning, and homelessness measures. A significant minority of low-income U.S. veterans reported gambling, with 24.9% (95% confidence interval [CI] 95% CI 21.12-28.76%) exhibiting RG and 6.7% (95% CI 3.88-9.42%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White veterans. ARPG was associated with greater symptoms of substance use and anxiety; poorer physical functioning; history of any mental illness; lifetime history of homelessness; and having any student or car loans relative to NG. Veterans who had RG were more likely to screen positive for drug use disorders relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among low-income U.S. veterans and underscore the importance of routine screening, monitoring, and development of interventions for problematic gambling severity, as well as interventions for ARPG in this population. These findings may inform targeted intervention strategies for this vulnerable subpopulation.

Lung Cancer Screening Among U.S. Military Veterans by Health Status and Race and Ethnicity, 2017–2020: A Cross-Sectional Population-Based Study

Veterans are at high risk for lung cancer and are an important group for lung cancer screening. Previous research suggests that lung cancer screening may not be reaching healthier and/or non-White individuals, who stand to benefit most from lung cancer screening. We sought to test whether lung cancer screening is associated with poor health and/or race and ethnicity among veterans. This cross-sectional, population-based study included veterans eligible for lung cancer screening (aged 55-79 years, ≥30 pack-year smoking history, current smokers or quit within 15 years, no previous lung cancer) in the 2017-2020 Behavioral Risk Factor Surveillance System surveys. Exposures were (1) poor health, defined as fair/poor health status and difficulty walking or climbing stairs, aligning with eligibility criteria for a pivotal lung cancer screening trial, and (2) race/ethnicity. The outcome was a receipt of lung cancer screening. All variables were self-reported. Of 3,376 lung cancer screening-eligible veterans representing an underlying population of 866,000 individuals, 20.3% (95% CI=17.3, 23.6) had poor health, and 13.7% (95% CI=10.6, 17.5) identified as non-White. Poor health was strongly associated with lung cancer screening (adjusted RR=1.64, 95% CI=1.06, 2.27); one third of veterans screened for lung cancer would not qualify for a pivotal lung cancer screening trial in terms of health. Marked racial disparities were observed among veterans: after adjustment, non-White veterans were 67% less likely to report lung cancer screening than White veterans (adjusted RR=0.33, 95% CI=0.11, 0.66). Lung cancer screening is correlated with poorer health and White race/ethnicity among veterans, which may undermine its population-level effectiveness. These results highlight the need to promote lung cancer screening, especially for healthier and/or non-White veterans, an important group of Americans for lung cancer screening.

COVID-19 Outcomes and Genomic Characterization of SARS-CoV-2 Isolated From Veterans in New England States: Retrospective Analysis.

BackgroundClinical and virologic characteristics of COVID-19 infections in veterans in New England have not been described. The average US veteran is a male older than the general US population. SARS-CoV-2 infection is known to cause poorer outcomes among men and older adults, making the veteran population an especially vulnerable group for COVID-19.ObjectiveThis study aims to evaluate clinical and virologic factors impacting COVID-19 outcomes.MethodsThis retrospective chart review included 476 veterans in six New England states with confirmed SARS-CoV-2 infection between April and September 2020. Whole genome sequencing was performed on SARS-CoV-2 RNA isolated from these veterans, and the correlation of genomic data to clinical outcomes was evaluated. Clinical and demographic variables were collected by manual chart review and were correlated to the end points of peak disease severity (based on oxygenation requirements), hospitalization, and mortality using multivariate regression analyses.ResultsOf 476 veterans, 274 had complete and accessible charts. Of the 274 veterans, 92.7% (n=254) were men and 83.2% (n=228) were White, and the mean age was 63 years. In the multivariate regression, significant predictors of hospitalization (C statistic 0.75) were age (odds ratio [OR] 1.05, 95% CI 1.03-1.08) and non-White race (OR 2.39, 95% CI 1.13-5.01). Peak severity (C statistic 0.70) also varied by age (OR 1.07, 95% CI 1.03-1.11) and O2 requirement on admission (OR 45.7, 95% CI 18.79-111). Mortality (C statistic 0.87) was predicted by age (OR 1.06, 95% CI 1.01-1.11), dementia (OR 3.44, 95% CI 1.07-11.1), and O2 requirement on admission (OR 6.74, 95% CI 1.74-26.1). Most (291/299, 97.3%) of our samples were dominated by the spike protein D614G substitution and were from SARS-CoV-2 B.1 lineage or one of 37 different B.1 sublineages, with none representing more than 8.7% (26/299) of the cases.ConclusionsIn a cohort of veterans from the six New England states with a mean age of 63 years and a high comorbidity burden, age was the largest predictor of hospitalization, peak disease severity, and mortality. Non-White veterans were more likely to be hospitalized, and patients who required oxygen on admission were more likely to have severe disease and higher rates of mortality. Multiple SARS-CoV-2 lineages were distributed in patients in New England early in the COVID-19 era, mostly related to viruses from New York State with D614G mutation.

Binge Drinking and Heavy Drinking Among Older Military Veterans: Applying the Theory of Intersectionality

The post-service impact of military experiences include post-traumatic stress disorder, depression, substance misuse and several other adverse outcomes that persist well into older adulthood. As such, older military veterans are at risk of developing alcohol dependency and those with existing stressors from other identities are at the highest risk of engaging in binge drinking or heavy drinking. This study used the theory of intersectionality to examine alcohol misuse by veteran status and age, veteran status and race and veteran status and sex. Data were derived from the 2016, 2017 and 2018 Brief Risk Factor Surveillance System (BRFSS) from the Centers for Disease Control and Prevention (CDC). The BRFSS is an annual survey conducted over the phone in all 50 states and territories. Survey-weighted logistic regression models were used to examine alcohol misuse among adults aged 65+ by veteran status and the intersection between age, race, and sex. Results showed no interaction between veteran status and age, and no interaction between veteran status and sex. However, there was a significant interaction between veteran status and race, in that Black/Other race veterans were more likely to engage in both binge drinking and heavy drinking compared to White veterans, White nonveterans and nonveterans of the same race. Interventions geared towards this population should therefore engage culturally sensitive approaches that consider the historical and systemic factors that contribute to these disparities in rates of alcohol misuse among older military veterans.

The Association Between Veteran Status and Obesity Differs Across Race/Ethnicity.

This study aims to evaluate the interaction between veteran status and race/ethnicity on obesity status. Cross-sectional survey. The 2013-2017 National Health Interview Survey. A total of 151,765 adults (8.62% veterans and 91.38 nonveterans) with 69.30% identifying as White, 13.05% identifying as Hispanic, 12.57% identifying as Black, and 5.08% identifying as Asian. Obesity status (measured using self-reported body mass index), race/ethnicity, survey year, age, marital status, educational attainment, federal poverty level, health insurance, type of insurance, self-reported health status, and whether participant had a usual care source. Weighted logistic regression analysis. In a fully adjusted model, there was no evidence that veterans overall had higher odds of obesity compared to nonveterans (adjusted odd ratio (aOR): 1.05, 95% CI: .99, 1.11). White veterans had lower odds of obesity compared to White nonveterans (OR: .93, 95% CI: .87, .98). Hispanic veterans had higher odds of obesity compared to Hispanic nonveterans (aOR: 1.53, 95% CI: 1.23, 1.90). There was no evidence of an association between veteran status and obesity status for Black and Asian adults. Effectual prevention strategies are needed to decrease obesity risks among active and retired Hispanic veterans.

Abstract P118: Machine Learning Algorithm For Improving Classification Of Myocardial Infarction Across A Diverse Population Using US Veteran Electronic Health Record Data

Introduction: The majority of population-based studies of myocardial infarction (MI) rely on billing codes for classification. Classification algorithms employing machine learning (ML) increasingly used for phenotyping using electronic health record (EHR) data. Hypothesis: ML algorithms integrating billing and information from narrative notes extracted using natural language processing (NLP) can improve classification of MI compared to billing code algorithms. Improved classification will improve power to compare risk factors across population subgroups. Methods: Retrospective cohort study of nationwide Veterans Affairs (VA) EHR data. MI classified using 2 approaches: (1) published billing code algorithm, (2) published phenotyping pipeline incorporating NLP and ML. Results compared against gold standard chart review of MI outcomes in 308 Veterans. We also tested known association between high density lipoprotein cholesterol (HDL-C) and MI outcomes classified using the 2 approaches among Black and White Veterans, stratified by sex and race; prior study showed HDL-C less protective for Black compared to White individuals. Results: We studied 17,176,658 million Veterans, mean age 69 years, 94% male, 12% self-report Black, 71% White. The billing code algorithm classified MI at positive predictive value (PPV) 0.64 compared to the published ML approach, PPV 0.90; the latter classified a modestly higher percentage of non-White Veterans. Using ML algorithm for MI, we replicated a reduced protective effect of HDL-C in Black vs White male and female Veterans (Table); with the billing code algorithm no association was observed between low density lipoprotein cholesterol (LDL-C) or HDL-C with MI among Black female Veterans. Conclusions: Using nationwide VA data, application of an ML approach improved classification of MI particularly among non-White Veterans, resulting in improved power to study differences in association for MI risk factors among Black and White Veterans.

Alcohol misuse among older military veterans: an intersectionality theory perspective

Background Alcohol misuse among older adults is an emerging public health issue. Older veterans are particularly at risk of developing substance use dependency due to the enduring impacts of military service. The purpose of this study was to test the theory of intersectionality on alcohol misuse by veteran status and age, veteran status and sex, and veteran status and race. Methods Combined data from the 2016, 2017, and 2018 Brief Risk Factor Resilience Survey (BRFSS) from the Centers for Disease Control and Prevention (CDC) were used in this cross-sectional study. The BRFSS is conducted annually with adults via landline or cellular telephones in all 50 states in the United States, as well as in the District of Columbia, Puerto Rico, and Guam. Alcohol misuse among individuals aged 65+ was examined by veteran status and the interaction between age, race, and sex using survey-weighted logistic regression models. Results Results show no interaction between veteran status and age or sex. For the interaction between veteran status and race, significant disparities were found. Black/Other race veterans were significantly more likely to engage in binge drinking and heavy drinking compared to nonveterans of the same race, White veterans, and White nonveterans. Conclusion Older veterans who are also Black, Indigenous and/or people of color (BIPOC) are at great risk of engaging in alcohol misuse due to the combined stressors from their intersectional identities. Interventions targeting this population should consider the historical, cultural, and systemic factors that contribute to a disproportionally higher rate of binge drinking and heavy drinking among BIPOC veterans.

Home Telehealth Technologies for Heart Failure: An Examination of Adherence Among Veterans.

The current retrospective cohort study uses Department of Veterans Affairs (VA) clinical and facility data of Veterans with heart failure enrolled in the VA Home Tele-health (HT) Program. General estimating equations with facility as a covariate were used to model percent average adherence at 1, 3, 6, and 12 months post-enrollment. Most HT patients were White, male, and of older age (mean = 71 years). Average adherence increased the longer patients remained in the HT program. Number of weekly reports of HT use, not having depression, and being of older age were all associated with higher adherence. Compared to White Veterans, Black and other non-White Veterans had lower adherence. These findings identify subgroups of patients (e.g., those with depression, of younger age, non-White) that may benefit from additional efforts to improve adherence to HT technologies. [Journal of Gerontological Nursing, 46(7), 26-34.].

A complementary and integrative health group-based program pilot demonstrates positive health outcomes with female Veterans

IntroductionTransforming Health and Resiliency through Integration of Values-based Experiences (THRIVE) is an evidence-based 14-week curriculum-based group medical appointment clinical program. THRIVE is based on principles of integrative medicine, positive psychology, and acceptance and commitment therapy. The goal of this paper is to review findings from a local THRIVE program implementation piloted in the Women's Health outpatient clinics on mental and physical health indicators. Materials and methodsPilot data were obtained for 14 THRIVE cohorts of female veterans enrolled from outpatient clinics at the James A. Haley veterans’ Hospital in Tampa, FL between 2016 and 2018 (N = 201). THRIVE assessments were conducted as part of the THRIVE program, at the first visit (baseline), mid-way, and at the end of the program. Data were collected using self-administered paper-pencil method on standardized scales for physical and mental health (Patient Health Questionnaire, Generalized Anxiety Disorder Questionnaire, Acceptance and Action Questionnaire-II, Satisfaction With Life Scale, and the physical and mental function components of the Short Form Survey). Linear mixed effects models were used to examine change in physical and mental health scales over time while adjusting for age, race (white vs. other), and cohort. In addition, we examined whether the rate of change differed by age or race. ResultsImprovement was seen for most scales across the 3 assessments (p < 0.05) with the exception of physical composite score of the Short Form Survey (p = 0.487). Participants reported that pain interfering with work significantly decreased from “quite a bit” at baseline to “moderately” by assessment 3 (p = 0.042). Older ages had lower baseline scores on the Patient Health Questionnaire and Acceptance and Action Questionnaire than younger ages, but younger ages had a greater rate of improvement over the intervention (p for interaction 0.016 and 0.056, respectively). Whites reported greater improvement in life satisfaction than non-whites (p for interaction 0.043). For physical composite score, whites had higher baseline score, but did not report significant improvement in physical function over the assessment period, while non-whites had lower baseline score, but did report significant improvement in physical function (p for interaction 0.059). Non-white veterans reported more pain interfering with work relative to white veterans (OR 5.9, 95% CI 1.79–19.43, p = 0.004). ConclusionsWe found significant improvement on self-reported mental health scales as well as improvement in how much pain interferes with work in a pilot sample of women veterans over the 14-week program.

The Impact of Social Determinants of Health on Hospitalization in the Veterans Health Administration

This study aims to assess the effect of individual and geographic-level social determinants of health on risk of hospitalization in the Veterans Health Administration primary care clinics known as the Patient Aligned Care Team. For a population of Veterans enrolled in the primary care clinics, the study team extracted patient-level characteristics and healthcare utilization records from 2015 Veterans Health Administration electronic health record data. They also collected census data on social determinants of health factors for all U.S. census tracts. They used generalized estimating equation modeling and a spatial-based GIS analysis to assess the role of key social determinants of health on hospitalization. Data analysis was completed in 2018. A total of 6.63% of the Veterans Health Administration population was hospitalized during 2015. Most of the hospitalized patients were male (93.40%) and white (68.80%); the mean age was 64.5 years. In the generalized estimating equation model, white Veterans had a 15% decreased odds of hospitalization compared with non-white Veterans. After controlling for patient-level characteristics, Veterans residing in census tracts with the higher neighborhood SES index experienced decreased odds of hospitalization. A spatial-based analysis presented variations in the hospitalization rate across the Veterans Health Administration primary care clinics and identified the clinic sites with an elevated risk of hospitalization (hotspots) compared with other clinics across the country. By linking patient and population-level data at a geographic level, social determinants of health assessments can help with designing population health interventions and identifying features leading to potentially unnecessary hospitalization in selected geographic areas that appear to be outliers.

Military and Crime: A Systematic Review of the Literature

ABSTRACTThis study systematically analyzed the literature on the effects of military participation on later criminal behavior. When all studies were analyzed as a whole, the findings did not indicate a clear effect. However, a focus upon specific offense types revealed that the military experience decreased non-violent crime but increased violent crime. Active military personnel tended to be less likely to commit crime. Some evidence demonstrated that male and non-white veterans committed more crime than their civilian counterparts, but future research is needed to replicate these subgroup differences. Theoretical implications and future research directions are also discussed.

The Impact of Veteran Status on Life-Space Mobility among Older Black and White Men in the Deep South.

To examine life-space mobility over 8.5 years among older Black and White male veterans and non-veterans in the Deep South. A prospective longitudinal study of community-dwelling Black and White male adults aged >65 years (N=501; mean age=74.9; 50% Black and 50% White) enrolled in the University of Alabama at Birmingham (UAB) Study of Aging. Data from baseline in-home assessments with follow-up telephone assessments of life-space mobility completed every 6 months were used in linear mixed-effects modeling analyses to examine life-space mobility trajectories. Life-space mobility. In comparison to veterans, non-veterans were more likely to be Black, single, and live in rural areas. They also reported lower income and education. Veterans had higher baseline life-space (73.7 vs 64.9 for non-veterans; P<.001). Race-veteran subgroup analyses revealed significant differences in demographics, comorbidity, cognition, and physical function. Relative to Black veterans, there were significantly greater declines in life-space trajectories for White non-veterans (P=.009), but not for White veterans (P=.807) nor Black non-veterans (P=.633). Mortality at 8.5 years was 43.5% for veterans and 49.5% for non-veterans (P=.190) with no significant differences by race-veteran status. Veterans had significantly higher baseline life-space mobility. There were significantly greater declines in life-space trajectories for White non-veterans in comparison to other race-veteran subgroups. Black veterans and non-veterans did not have significantly different trajectories.

Combat exposure, social relationships, and subjective well-being among middle-aged and older Veterans

Objectives: This study described the association of subjective well-being with combat exposure and social relationships among middle-aged and older Veteran men in the USA. The stress-buffering hypothesis, which predicts social relationships may moderate the association between combat exposure and subjective well-being, was also examined.Method: Data from the 2008 Health and Retirement Study (N = 2961) were used to estimate logistic regression models, focusing on three measures of subjective well-being: depression, life satisfaction, and self-reported health.Results: In the fully adjusted models, there were no statistically significant relationships between combat exposure and the three indicators of subjective well-being. However, compared to Veterans who had lower scores on the social relationship index, Veterans who had higher scores were less likely to be depressed and less likely to report poor or fair health. Veterans who had higher scores on the social relationships index reported higher levels of life satisfaction than those Veterans who had lower scores. There was no evidence for a social relationships buffering effect.Conclusion: The results of this study demonstrated that combat exposure did not have a long-term relationship with subjective well-being. Longitudinal research designs with more comprehensive indicators of combat exposure may help researchers better understand some of the underlying complexity of this relationship. Complementary research with samples of women Veterans, as well as samples of Hispanic, and non-Black, non-White Veterans, is also needed.

Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans

BackgroundWe sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs′ (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder. MethodsWe retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers′ primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments. ResultsOf 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively). LimitationsStudy findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment. ConclusionsSI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden.

Race, Place, and Veteran Status: Migration among Black and White Men, 1940–2000

In this paper, I gauge the impact of veteran status on migration probabilities for black and white men in the late 20th century United States, comparing cohorts that were subject to various military staffing policies. I find that white veterans are more likely than are white non-veterans to live outside the state of their birth and to have recently migrated. These effects persist regardless of whether veterans were subject to the draft or the All Volunteer Force staffing policy, and are durable across the life course. Among blacks, elevated rates of veterans’ migration are first observed in 1980. These results illuminate a previously unidentified consequence of veteran status, and may point to a policy-linked mechanism through which prior military employment influences social mobility, the American labor force is redistributed, and the racial composition of states and localities is altered.

Racial/ethnic and educational-level differences in diabetes care experiences in primary care

To assess potential racial/ethnic and educational-level differences in the degree to which patients with diabetes who receive primary care from a Veterans Affairs Medical Center report that experiences with the diabetes care system are consistent with the Chronic Care Model (CCM). A cross-sectional mailed survey of 296 patients included the Patient Assessment of Chronic Illness Care (PACIC), which measures components of the care system suggested by the CCM. Among 189 patients with complete information, non-white veterans had more than twice the odds of indicating that their diabetes care experience is in line with the CCM [measured by overall PACIC score > or =3.5] (OR 2.3; 95% CI 1.3-4.1). Non-white veterans were more likely to report high levels of assistance with problem solving and follow-up. Patients not completing high school had three times the odds of reporting care in line with the CCM (OR 3.0; 95% CI 1.2-7.6). Associations were also seen with implementation of the CCM in the areas of patient activation, perceived care teams, collaborative goal setting, and collaborative problem solving. Non-white patients and those with less than a high school education had more than twice the odds of reporting that the diabetes care system is in line with the CCM.

Risk of Incarceration among Male Veterans and Nonveterans

In this study, we used data from national surveys of U.S. veterans and nonveterans to investigate whether military service increased risk for incarceration compared to non-veteran peers. White veterans aged thirty-five to fifty-four (early years of the All Volunteer Force and the Vietnam era) were at higher risk for incarceration than white nonveterans. Black and Hispanic veterans of these eras were generally at lower risk of incarceration than age-and race-matched nonveterans. For all racial/ethnic groups, the risk of incarceration among veterans compared to nonveterans declined among those who served in the later years of the implementation of the All Volunteer Force. These findings may reflect the disadvantaged backgrounds of recruits during the early implementation of the All Volunteer Force, from 1973 to 1980, and the improved quality of personnel recruited after 1980. Among all males, the risk of incarceration was not elevated among Vietnam-era and World War II veterans.

Pilot Study of Pain and Coping Among Patients With Osteoarthritis

Few studies have examined patterns of pain and coping among patients with osteoarthritis (OA). This pilot study used a daily diary approach to examine pain and coping strategy use among white and nonwhite veterans with OA. Participants (23 white, 13 nonwhite; 89% male; mean age = 63 years) completed diaries of pain (10-cm visual analog scale) and coping (total, problem-focused, and emotion-focused) for 30 days. Analyses examined relationships of mean self-reported pain severity and variability with coping strategy use as well as racial differences in these associations. The mean pain level (4.46 [scale of 0-10], standard deviation [SD] = 2.12) and mean within-subject pain variance (1.94, SD = 1.79) were similar between white and nonwhite participants. With respect to pain variability, 2 distinct subgroups were observed, with approximately half of participants reporting high variability and half reporting low variability. The mean total coping score (on a scale of 0-7) was 2.62 (SD = 1.77), with problem-focused strategies being used more often than emotion-focused. There were no significant associations between coping (total, problem-focused, and emotion-focused) and mean pain severity, but the direction of these relationships differed according to race. Results of this pilot study showed considerable between-subject variability in pain and coping strategy use as well as some racial differences. Medical treatment and self-management approaches may be improved if they can be tailored according to patients' pain patterns and preferred coping strategies.

Geographical proximity and health care utilization in veterans with SCI&D in the USA

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans’ likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.