Lead/Presenter: Katherine Hoggatt, COIN - Los Angeles
All Authors: Hoggatt KJ (Center for the Study of Healthcare Innovation, Implementation, & Policy, Los Angeles; UCLA Fielding School of Public Health), Harris AHS (Center for Innovation to Implementation (Ci2i), , VA Palo Alto Health Care System, Menlo Park, CA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA) Washington DL (Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA) Haderlein T (Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA) Williams EC (Center of Innovation for Veteran Centered and Value-Driven Care, VA Puget Sound, Seattle, WA; Department of Health Services, University of Washington, Seattle, WA)
Substance use disorder (SUD) is common among VA patients, but accurate prevalence estimation is challenging because electronic health record (EHR) data may underestimate true disease burden and fail to identify high-risk subgroups. We directly surveyed VA patients to estimate true SUD prevalence and identify high-prevalence subgroups. We also examined whether SUD prevalence differs between patients who exclusively use VA care or additionally use community care.
We conducted a telephone-based survey with VA outpatients (N = 5,267) from 30 geographically-representative VA healthcare systems. Past-year alcohol and drug use disorders (AUD, DUD; collectively, SUD) were measured using validated items to assess DSM-5 criteria. We compared prevalence across subgroups defined by demographics (age, gender, race/ethnicity), socioeconomic status (SES: education, marital status, employment), and healthcare (health insurance status, non-VA healthcare use). Logistic regression models with all variables entered simultaneously were fit to estimate adjusted prevalence differences for exclusive VA vs. community care users.
Prevalence of AUD, DUD, and SUD was 10%, 5%, and 13%, respectively. SUD prevalence was highest for patients 18-34 years old (27%), male (13%), Hispanic (21%) or Black (17%), never married (20%), with some college education (14%), unemployed (27%), with no non-VA medical insurance (17%), and using VA healthcare exclusively (16%). After adjusting for demographics, SES, and health insurance, exclusive VA users were more likely, relative to patients who used mainly community care, to meet criteria for DUD (difference = 2 percentage points, p = 0.04) or SUD (difference = 3 percentage points, p = 0.04) but not AUD (p = 0.20).
One in eight VA patients meets diagnostic criteria for SUD, with higher prevalence among patients who exclusively use VA and up to double the prevalence in key vulnerable populations (e.g., younger or unemployed patients). Survey-based prevalence estimates were markedly higher than previously-reported, EHR-based estimates.
SUD is a leading cause of death in the US and more prevalent among VA patients than previously reported. Ensuring access to evidence-based SUD treatment in VA should remain a high priority and may require expanding VA screening to include drugs in addition to alcohol. Mitigating the burden of SUD among VA patients may require targeted efforts for specific sub-populations, such as young or unemployed Veterans.