White Veterans Research Articles

Provision of Home & Community Based Services to Veterans by Race, Rurality, and Neighborhood Deprivation Index.

Home and community-based services (HCBS) enable frail patients to remain at home. We examined whether there were neighborhood-deprivation, racial, or rural disparities in HCBS utilization provided to Veterans by the Department of Veterans Affairs (VA) or Medicare by comparing the adjusted utilization rate of a historically disadvantaged group with the predicted utilization rate had it been treated as the historically dominant group. Among the 2.7 million VA patients over 66 years old in 2019, 11.0% were Black, 39.2% lived in rural settings, 15.3%/29.2%/30.9%/24.7% lived in least/mild/moderate/most-deprived neighborhoods. On average, 11.2% received VA or Medicare HCBS. Veterans residing in more deprived neighborhoods had 0.11-0.95% higher adjusted probability of receiving HCBS than expected had they resided in the least deprived neighborhoods. Veterans residing in rural areas had 0-0.7% lower HCBS rates than expected had they been treated like urban Veterans. Black Veterans were 0.8-1.2% more likely to receive HCBS than expected had they been treated like White Veterans. Findings indicate that VA resources were equitably employed, aligning with probable HCBS needs, suggesting that VA's substantial and long-standing investment in HCBS for care of frail Veterans could serve as a model for other payers and providers in the U.S.

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.

Age-Dependent Racial Differences in Kidney Function Decline between Black and White Veterans after CKD Onset

Age-Dependent Racial Differences in Kidney Function Decline between Black and White Veterans after CKD Onset

Women Veterans' Stroke Risk Factors: Identified Prevention Methods and Knowledge Gaps.

Stroke is a significant health burden for veterans and the fifth leading cause of death for women. Compared to civilian women, women veterans have significant multimorbid physical and mental health conditions contributing to their stroke risk. This scoping review aimed to synthesize evidence on the stroke risk factors specific to U.S. women veterans and identify any association between risk factors and a delay in prevention and treatment for women veterans. This study was approved by the organizational Institutional Review Board. The search strategy was run across 6 databases: MEDLINE and EMBASE via Ovid, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. A total of 1218 records were uploaded to Covidence for screening. Criteria for included studies were peer-reviewed primary research articles written in English about women veterans and cardiovascular disease and stroke risk factors. No restrictions were placed on publication date. Fourteen articles met the inclusion criteria. Cohorts were 30 years and older. Data originated from national and individual Veterans Affairs studies. Women veterans starting at age 30 have a steadily increasing positive curvilinear association with stroke risk, indicating a need to screen earlier than the recommended age of 45 years. Stroke incidence was higher in veterans with post-traumatic stress disorder, insomnia, restless leg syndrome, traumatic brain injury, constipation with laxative use, egg consumption (2-4 eggs/wk), frailty, and systemic sclerosis. When comparing White veterans and civilian counterparts, Black veterans had a higher incidence of stroke. Ten studies addressed prevention methods. The clinicians should screen and treat women veterans for post-traumatic stress disorder and constipation and consider alternative treatment methods for constipation. Empirical literature on this matter is lacking. Examining and understanding the differences in sex, gender, and veteran status, and their association with stroke risk, is warranted. Screening women veterans for post-traumatic stress disorder and for stroke early, at 30 years of age, is recommended.

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.

Assessing the Relationship Between Sleep Duration and the Prevalence of Chronic Kidney Disease Among Veterans in the United States: A 2022 Behavior Risk Factor Surveillance System (BRFSS) Cross-Sectional Study.

Chronic kidney disease (CKD) is more prevalent among veterans in the United States than in the general population. Similarly, veterans also exhibit higher rates of abnormal sleep duration compared to the general population. The aim of this study was to investigate the association between self-reported length of sleep and the prevalence of CKD among veterans in the United States using responses from the 2022 Behavioral Risk Factor Surveillance System (BRFSS). For this cross-sectional study, a total of 53,211 veterans who responded to the 2022 BRFSS survey were analyzed. Measures include the outcome variable which is self-reported CKD diagnosis and a major independent variable sleep duration. Sleep duration was recategorized into ≤ 5 hours (short sleep duration), 6-10 hours (normal sleep duration), and >10 hours (long sleep duration). Covariates included gender, age, race, residence, insurance, alcohol consumption, diabetes comorbidity, coronary artery disease (CAD) comorbidity, and stroke comorbidity. Descriptive, bivariate, and multivariate logistic regressions were conducted using the SAS software (SAS Institute Inc., Cary, North Carolina, United States). Results: The prevalence of CKD among veterans in the United States is 3332 (6.29%). Veterans with sleep duration of 6-10 hours had 17.5% lower odds of CKD than veterans who slept for ≤5 hours (adjusted OR (AOR)= 0.825, 95%CI= 0.821-0.830; P=<0.0001). Veterans who slept for more than 10 hours had 68.2% higher odds of having CKD (AOR=1.682, 95%CI= 1.662-1.702; P=<0.0001). Additionally, veterans diagnosed with diabetes, stroke, and coronary artery disease had 2.447-2.103, and 2.838, respectively, higher odds of developing CKD (AOR=2.447, 95%CI= 2.435-2.459; p=<0.0001). Veterans who were 65 years and older had higher odds of developing CKD compared to those aged 35-44 years (AOR= 5.743, 95%CI= 5.669-5.818; P<0.001). The odds of having CKD were also higher among veterans who identified as Black (AOR 1.397, 95%CI =1.388-1.405; P<0.01) or as Hispanic (AOR =1.318, 95%CI = 1.307-1.329; P<0.01) compared to non-Hispanic White veterans. Those who identified as Asian had lower odds of CKD (AOR= 0.87, 95%CI=0.853-0.888; P<0.01). Furthermore, veterans who consumed alcohol had 7.8% lower odds of having CKD as compared to individuals who did not consume alcohol (AOR= 0.922, 95%CI =0.918-0.927; p=<0.0001). Male veterans had 24.7% lower odds of having CKD as compared to female veterans (AOR = 0.753, 95%CI= 0.747-0.758; P<0.001). Conclusion: This research provides evidence of a greater prevalence of CKD among veterans with short sleep duration (≤ 5 hours) and long sleep duration (> 10 hours). Sleep hygiene education and sleep optimization programs can improve sleep and boost overall kidney health among veterans.

United States Veterans' Utilization of Spinal Cord Injuries and Disorders Annual Evaluation Services

ObjectiveTo evaluate Veterans’ engagement in spinal cord injury and disorder (SCI/D) specialty annual evaluations (AEs). DesignCross-sectional retrospective cohort study. SettingSCI/D System of Care, United States Department of Veterans Affairs (VA). ParticipantsVeterans with SCI/Ds (N=14,662). InterventionsNot applicable. Main Outcome MeasuresReceiving SCI/D AEs during the study period (fiscal years [FY] 2019 and 2020). ResultsA total of 14,662 Veterans with SCI/Ds were included in the sample; 32.8% (n=4811) received 2 AEs, 28.8% (n=4219) received 1 AE, and 38.4% (n=5632) received no AEs, with an average of 0.9 AEs per Veteran over the 2-year study timeframe (range, 0-2y). Black Veterans had an 8% higher number of AEs than White Veterans after adjusting for other variables (adjusted relative risk [RR], 1.08; 95% confidence interval [CI], 1.04-1.12). Veterans who lived ≥240 minutes away from a VA SCI/D System of Care Center had 45% fewer AEs than Veterans who lived within 30 minutes (adjusted RR, 0.55; 95% CI, 0.52-0.59). Veterans with more SCI/D specialty visits had 90% more AEs than those with fewer visits (adjusted RR, 1.90; 95% CI, 1.78-2.03), whereas Veterans with more outpatient visits in VA primary care had 28% fewer AEs (adjusted RR, 0.72; 95% CI, 0.69-0.76). Veterans with higher comorbidity scores had 9% more AEs than Veterans with lower scores (adjusted RR, 0.66; 95% CI, 0.61-0.70). ConclusionsMore than half (62%) of Veterans received ≥1 SCI/D AE during FY19-20. Veterans living closer to a VA SCI/D System of Care Center/Hub had more engagement in SCI/D AEs. Veterans with SCI/Ds who used VA primary care outside of the SCI/D System of Care had fewer AEs. There were no major racial, age-based, or sex disparities in SCI/D AE usage. Our findings suggest the need for targeted intervention efforts to promote AE use among Veterans.

Examining Ethnoracial Differences in Retention in Evidence-Based Treatments for Posttraumatic Stress Disorder Secondary to Military Sexual Trauma.

Improving and expanding mental health treatment for Veterans who have experienced military sexual trauma (MST) is currently a top priority in Veterans Healthcare Administration. Many of these Veterans develop posttraumatic stress disorder (PTSD), and there is increasing recognition that diversity is a core treatment consideration for Veterans who have experienced trauma. As such, more information is needed concerning the relationship between trauma-focused treatment attrition and ethnoracial identity in Veterans who have experienced MST. This article presents two studies exploring dropout from a Midwestern Department of Veterans Affairs (VA) PTSD clinic in samples of Veterans who experienced MST. These studies aim to reduce this knowledge gap by contrasting Black and White Veterans' retention in trauma-focused care. In Study 1 (n = 141), we examined ethnoracial differences in dropout in a cohort of treatment-seeking Veterans who experienced MST and engaged in cognitive processing therapy (CPT) in a VA specialty PTSD clinic. In Study 2 (n = 109), we explored the same questions related to treatment attrition in a separate cohort of treatment-seeking Veterans who experienced MST and engaged in prolonged exposure (PE) in a VA specialty PTSD clinic. Results from both studies did not indicate ethnoracial differences in attrition rate (for both total sessions and an 8-week minimally adequate care [MAC] window) across evidence-based PTSD treatment. However, it remains important to consider the impact of racial and cultural factors on retention. Future research should aim to recruit a larger racially and ethnically diverse sample to explore possible varying retention outcomes of CPT and PE for MST-related PTSD.

Evaluating equity in a national virtual care management intervention: Delivery and outcomes by race/ethnicity among Veterans with hypertension and diabetes.

To evaluate whether the Preventive Health Inventory (PHI)-a virtual care management intervention addressing hypertension and diabetes management implemented nationally in the Veterans Health Administration (VHA)-was delivered equitably among racial/ethnic groups and if existing inequities in hypertension and diabetes outcomes changed following PHI receipt. We used data from the VHA Corporate Data Warehouse among Veterans enrolled in primary care nationally from February 28, 2021 to March 31, 2022. We used logistic regression to evaluate PHI receipt and hypertension and diabetes outcomes after PHI implementation among Veterans with hypertension and/or diabetes. We conducted unadjusted analyses and analyses adjusting for clinic fixed effects using dummy variables. We identified Veterans engaged in primary care with documented race/ethnicity and hypertension and/or diabetes diagnoses in all months during the study period. Prior to PHI, Non-Hispanic Black (NHB) (42.2%) and Hispanic (39.5%) Veterans were less likely to have controlled hypertension vs. Non-Hispanic White (NHW) Veterans (47.5%); NHB Veterans (32.9%) were more likely to have uncontrolled diabetes vs. NHW Veterans (25.1%). Among 1,805,658 Veterans, 5.7% NHW (N = 68,744), 5.6% NHB (N = 22,580), 10.2% Hispanic (N = 13,313), 6.2% Asian/Pacific Islander/Native Hawaiian (N = 1868), 5.1% American Indian/Native Alaskan (N = 744), and 5.6% multiple races or other race (N = 1647) Veterans received PHI. We found no significant racial inequities in PHI receipt in unadjusted and adjusted models. Hypertension and diabetes measures improved more in the intervention group compared with the group who did not receive the intervention. There were no new or worsened inequities after PHI, and in pre-/post-intervention analysis, among NHB Veterans, the inequity in uncontrolled diabetes improved by 1.9 percentage points (95% CI 0.2, 3.6). Our findings suggest the PHI intervention was equitably deployed across race/ethnicity groups without significantly impacting most existing inequities in diabetes and hypertension.

Understanding Racial Disparities in Dementia Prevalence Among Veterans.

Black and Hispanic older adults have greater incidence of Alzheimer's disease and related dementias relative to White adults, but factors underlying these disparities are not well understood, limiting the ability to address them. To determine the impact of demographics, cardiovascular disease (CVD) and risk factors, social determinants of health (SDOH), and neuropsychiatric risk factors on racial/ethnic disparities in dementia risk among Veterans. We examined a random sample of 1,579,919 older Veterans (age ≥55) without dementia who received care from the VHA from October 1, 1999 to September 30, 2021. All variables were extracted from national VHA data. We used Cox proportional hazard regression models to examine change in variance in risk of dementia across racial/ethnic groups. During follow up (mean 11.1 years), 13% of Veterans developed dementia. Relative to White Veterans, the adjusted hazard ratios (AHRs) for developing dementia in sex-adjusted models with age as timescale were 1.65 (95% CI, 1.63-1.67) for Black Veterans and 1.50 (95% CI, 1.44-1.56) for Hispanic Veterans. In the model examining CVD and risk factors, AHRs were 1.53 (95% CI, 1.50-1.55) for Black Veterans and 1.38 (95% CI, 1.33-1.44) for Hispanic Veterans. In the model examining SDOH, AHRs were 1.46 (95% CI, 1.43-1.49) for Black Veterans and 1.34 (95% CI, 1.29-1.40) for Hispanic Veterans. SDOH and CVD and risk factors accounted for the greatest amount of variance in racial/ethnic disparities in dementia risk. Cardiovascular disease and SDOH are strong possible targets for interventions designed to reduce these disparities.

Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study

IntroductionThe U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. MethodsThis retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. ResultsMost of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. ConclusionAlthough buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.

‘Becoming manly’: white South African defence force veterans negotiating masculinity

ABSTRACT This study examines how white South African men reflect on their experiences of being and becoming army veterans, while negotiating masculinity. In the context of ‘high apartheid’, Afrikaner domination of the socio-political landscape, ethnic and racialised inequalities, the veterans negotiated being white English-speaking men through reflecting on, critiquing and disassociating from military masculinity. An English South African masculinity was upheld by distancing from Afrikaner domination and values, violence and compulsory heterosexuality. These findings suggest that while a military masculinity offered men a powerful template to assert their authority as white men, such power was nuanced by English South Africans’ relative political impotence, the domination of Afrikaans as a language and illustrates the heterogeneity in the experience of white veteran masculinity under apartheid. At the same time, however, white English veterans were complicit in and benefitted from whiteness and the power accrued in the country by virtue of race, class and history of British colonialism. We argue that the experience of being and becoming conscripts and the reflection on military masculinity directs attention to the ways in which broader social and political contexts have effects for the shaping of masculinity reflecting hierarchies of power and fluidity.

Ethnoracial Disparities in Perinatal Outcomes Among Women Veterans.

Objective: Non-Hispanic Black women have increased rates of preterm birth and low infant birth weight. However, we do not know if these disparities replicate in women veterans, a population that may be at further risk for poor perinatal outcomes. This study sought to examine ethnoracial differences in preterm birth and low infant birth weight in veterans. Methods: A national sample of randomly chosen women veterans (i.e., oversampled for residency in high crime neighborhoods) reported information about all pregnancies they have had in their life, demographic characteristics, and history of childhood trauma exposures. The analytic sample was limited to individuals who identified as Hispanic/Latinx, Black, or White (n = 972). Mixed-effects regression models were used to examine ethnoracial differences in gestational age at delivery and infant birth weight, controlling for age at pregnancy, childhood trauma exposure, pregnancy during military service, income, and education. Results: Both Black and Hispanic/Latinx veterans were significantly more likely to have an infant born at lower gestational age (B = -1.04 and B = -1.11, respectively) and lower infant birth weight (B = -195.83 and B = -144.27, respectively) as compared with White veterans in covariate-adjusted models. Black (odds ratio = 3.24, confidence interval = 1.16, 9.09) veterans were more likely to meet the clinical definition of preterm birth as compared with White veterans. Conclusions: Results align with what is seen in the general population regarding ethnoracial disparities in gestational age at delivery and infant birth weight. Findings highlight the critical need for more research on mechanisms and prevention efforts for ethnoracial disparities in perinatal outcomes.

Associations between PTSD and temporal discounting: The role of future thinking

Background and objectivesDespite documented alterations in future thinking in posttraumatic stress disorder (PTSD), our understanding of how individuals with PTSD make future-oriented decisions is limited. We tested the hypothesis that increased discounting in association with PTSD reflects failure to spontaneously envision future rewarding situations. MethodsThirty-seven trauma exposed war-zone veterans completed a standard temporal discounting task as well as a temporal discounting task accompanied by episodic future thinking cues. ResultsSeverity of PTSD symptoms was associated with preference for sooner, smaller rewards in the standard task. Consistent with our hypothesis, when participants engaged in future thinking, greater PTSD symptom severity was no longer associated with steeper discounting. Moreover, difficulty anticipating future events, as measured contemporaneously in a separate task (Verfaellie et al., 2024), mediated the relationship between PTSD symptom severity and degree of discounting in the standard task. Among PTSD symptom clusters, the severity of avoidance and negative alterations in cognition and mood was related to steeper discounting. Measures of depression and alcohol use were not associated with discounting. LimitationsThe sample included mostly male, predominantly White veterans who experienced primarily combat-related trauma. ConclusionsPTSD-associated alterations in temporal discounting reflect failure to spontaneously imagine future positive events. Two common correlates of PTSD, depression and alcohol use, could not account for the observed associations between PTSD and future-oriented decisions.

Exploring the properties of the Intersectional Discrimination Index — Major in Canadian Veterans with chronic pain

LAY SUMMARY In this study, the utility of a new self-report scale to capture experiences of discrimination or violence among a sample of Canadian military Veterans with chronic pain was evaluated. The Intersectional Discrimination Index — Major (InDI-M) was administered through an online survey along with other scales to measure experiences of pain, mood disorder, and functional interference. Results indicate that the InDI-M appears to measure both experiences of interpersonal violence and of systemic inequity, although some problems were identified when using the scale in this sample of predominantly white male Veterans. The InDI-M might be a useful research tool for exploring effects of interpersonal violence on pain and mental health but less so for exploring experiences of systemic inequity in military Veteran health research.

Racial and Ethnic and Rural Variations in Access to Primary Care for Veterans Following the MISSION Act

The 2018 Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act was implemented to increase timely access to care by expanding veterans' opportunities to receive Veterans Affairs (VA)-purchased care in the community (community care [CC]). Because health equity is a major VA priority, it is important to know whether Black and Hispanic veterans compared with White veterans experienced equitable access to primary care within the VA MISSION Act. To examine whether utilization of and wait times for primary care differed between Black and Hispanic veterans compared with White veterans in rural and urban areas after the implementation of the VA MISSION Act. This cross-sectional study used VA and CC outpatient and consult data from the VA's Corporate Data Warehouse for fiscal years 2021 to 2022 (October 1, 2020, to September 30, 2022). Separate fixed-effects multivariable models were run to predict CC utilization and wait times. Each model was run twice, once comparing Black and White veterans and then comparing Hispanic and White veterans. Adjusted risk ratios (ARRs) were calculated for Black and Hispanic veterans compared with White veterans within rurality status for both outcomes. VA and CC primary care utilization as measured by primary care visits (utilization cohort); VA and CC primary care access as measured by mean wait times (access cohort). A total of 5 046 087 veterans (994 517 [19.7%] Black, 390 870 [7.7%] Hispanic, and 3 660 700 [72.6%] White individuals) used primary care from fiscal years 2021 to 2022. Utilization increased for all 3 racial and ethnicity groups, more so in CC than VA primary care. ARRs were significantly less than 1 regardless of rurality status, indicating Black and Hispanic veterans compared with White veterans were less likely to utilize CC for primary care. There were 468 246 primary care consultations during the study period. The overall mean (SD) wait time was 33.3 (32.4) days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. Black veterans compared with White veterans had significantly longer wait times in CC (ARRs >1) but significantly shorter wait times in VA (ARRS <1) regardless of rurality status in VA and CC. CC wait times for Hispanic veterans compared with White veterans were longer in rural areas only and in VA rural and urban areas (ARRs >1). The results of this cross-sectional study suggest that additional research should explore the determinants and implications of utilization differences among Black and Hispanic veterans compared with White veterans. Efforts to promote equitable primary care access for all veterans are needed so that policy changes can be more effective in ensuring timely access to care for all veterans.

Long term follow up of monoclonal gammopathy of undetermined significance (MGUS) in US Veterans: Racial differences and associations with other malignancies.

7573 Background: Monoclonal gammopathy of undetermined significance (MGUS) is associated with lymphoid malignancies such as lymphoma and myeloma, but the association with other malignancies has not been described in the US veteran population. Methods: Veterans diagnosed with MGUS from 1991-2023 were identified from the US Veteran Affairs Central Cancer Registry (VACCR). Age at the diagnosis of MGUS was divided into four categories of &lt;60, 60-69, 70-79, 80+. Variables collected included demographic factors and the diagnosis of other cancers. Differences were analyzed using the Chi Square test. Results: There were 3975 veterans who met the criteria. Most patients were male (96.7%) with a median age at diagnosis of MGUS of 70.5 (IQR 65.4-76.0). Almost 1/3 of patients were Black and were diagnosed with MGUS at a younger age compared to White veterans (Table, p&lt;0.0001). Over the 32-year period included in this study, 2/3 of patients remained with a diagnosis of MGUS (62.3%) alone whereas 29.4% had 1 additional malignancy diagnosed and 8.3% had 2 or more additional malignancies. Black veterans with MGUS were more likely to have additional malignancies than white patients (41.4% vs 35.9%, p=0.016). MGUS was diagnosed prior to other cancers in 52% of patients and afterward in 48%. The most common cancers diagnosed in patients with MGUS were prostate (31%), lymphomas (13%), GI (12.5%), lung (12.0%), and skin (6.8%). CLL (3.4%), LPL (3.0%). Among lymphomas, CLL (3.4%) and LPL (3.0%) were most common. Of note, multiple myeloma or plasmacytoma was diagnosed in 6.5% of patients. The proportion of patients with MGUS and additional malignancies was comparable in the 4 age cohorts (p=0.072), indicating that younger patients with MGUS were as likely to be diagnosed with additional malignancies as older patients. Conclusions: In US veterans, nearly 1/3 of those diagnosed with MGUS were Black. These patients were younger when diagnosed with MGUS and were more likely to develop additional malignancies compared to White veterans. Over the 32 years of this study, a considerable proportion of veterans with MGUS developed various solid tumors. Further investigation is warranted to understand the racial, genetic, and other factors that may be contributing to the development of cancers in patients with MGUS. [Table: see text]

The Impact of Changing Race-Specific Equations for Lung Function Tests among Veterans with Chronic Obstructive Pulmonary Disease.

Rationale: The American Thoracic Society recommended a single reference equation for spirometry, but the impact on patients is not known. Objectives: To estimate the effect of changing to a single reference equation among veterans with chronic obstructive pulmonary disease (COPD). Methods: A cross-sectional study was conducted including veterans aged ⩾40 to ⩽89 years with COPD and spirometry results from 21 facilities between 2010 and 2019. We collected race and ethnicity data from the electronic health record. We estimated the percentage change in the number of veterans with lung function meeting clinical thresholds used to determine eligibility for lung resection for cancer, lung volume reduction surgery (LVRS), and lung transplantation referral. We estimated the change for each level of U.S. Department of Veterans Affairs service connection and financial impact. Results: We identified 44,892 veterans (Asian, 0.5%; Black, 11.8%; White, 80.8%; and Hispanic, 1.8%). When changing to a single reference equation, Asian and Black veterans had reduced predicted lung function that could result in less surgical lung resection (4.4% and 11.1%, respectively) while increasing LVRS (1.7% and 3.8%) and lung transplantation evaluation for Black veterans (1.2%). White veterans had increased predicted lung function and could experience increased lung resection (8.1%), with less LVRS (3.3%) and lung transplantation evaluation (0.9%). Some Asian and Black veterans could experience increases in monthly disability payments (+$540.38 and +$398.38), whereas White veterans could see a decrease (-$588.79). When aggregated, Hispanic veterans experienced changes attributable to their racial identity and, because this sample was predominantly Hispanic White, had similar results to White veterans. Conclusions: Changing the reference equation could affect access to treatment and disability benefits, depending on race. If adopted, the use of discrete clinical thresholds needs to be reassessed, considering patient-centered outcomes.

Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users.

To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level. We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019. We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender. We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence. Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination. We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.

Implications of Race Adjustment in Lung-Function Equations.

Adjustment for race is discouraged in lung-function testing, but the implications of adopting race-neutral equations have not been comprehensively quantified. We obtained longitudinal data from 369,077 participants in the National Health and Nutrition Examination Survey, U.K. Biobank, the Multi-Ethnic Study of Atherosclerosis, and the Organ Procurement and Transplantation Network. Using these data, we compared the race-based 2012 Global Lung Function Initiative (GLI-2012) equations with race-neutral equations introduced in 2022 (GLI-Global). Evaluated outcomes included national projections of clinical, occupational, and financial reclassifications; individual lung-allocation scores for transplantation priority; and concordance statistics (C statistics) for clinical prediction tasks. Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000. These potential changes differed according to race; for example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% (95% confidence interval [CI], 113 to 169) among Black persons and decreasing 69% (95% CI, 63 to 74) among White persons. Annual disability payments may increase by more than $1 billion among Black veterans and decrease by $0.5 billion among White veterans. GLI-2012 and GLI-Global equations had similar discriminative accuracy with regard to respiratory symptoms, health care utilization, new-onset disease, death from any cause, death related to respiratory disease, and death among persons on a transplant waiting list, with differences in C statistics ranging from -0.008 to 0.011. The use of race-based and race-neutral equations generated similarly accurate predictions of respiratory outcomes but assigned different disease classifications, occupational eligibility, and disability compensation for millions of persons, with effects diverging according to race. (Funded by the National Heart Lung and Blood Institute and the National Institute of Environmental Health Sciences.).