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  • Despite Equal Access and Use of VA Care, Black Veterans are More Likely to Experience Postpartum Rehospitalization and Low-Birthweight Infants
    This study sought to determine whether Black/white racial disparities in access, use, and outcomes are present among pregnant and postpartum Veterans and their infants using VA maternity care. Findings showed no statistically significant racial disparities in access or use of care during the perinatal period; nevertheless, Black Veterans were more likely than white Veterans to experience postpartum rehospitalization and to have a low-birthweight infant. After adjusting for age, rurality, and parity, Black Veterans were 67% more likely than white Veterans to have a postpartum rehospitalization and 67% more likely to have a low-birthweight infant. No other racial disparities in outcomes for birthing Veterans or their infants were detected. Approximately one-third of both Black and white Veterans reported needing mental healthcare during pregnancy. However, one in five Veterans were unable to access needed mental healthcare indicating there may be a persistent unmet need for perinatal mental healthcare. Study findings underscore the idea that access is necessary but not sufficient for ensuring health equity.
    Date: July 1, 2023
  • Thirty-Day Mortality Higher for Older Veterans Hospitalized with COVID-19 in Community vs. VA Hospitals
    This study compared outcomes among Veterans ages 65+ admitted for COVID-19 in VA and community hospitals. Findings showed that admission to community hospitals was associated with higher unadjusted (27% vs. 18%) and risk adjusted 30-day mortality compared to admission to VA hospitals. Readmission within 30 days was less common following admission to community compared to VA hospitals (13% vs. 14%). This difference was not sensitive to adjustment for patient characteristics, suggesting that higher readmission in VA hospitals may reflect a feature of the VA healthcare system and not case-mix. Community hospitals played a disproportionate role in care for rural Veterans with COVID-19, likely because of poor geographic access to VA hospitals among this population: 46% of community hospitals caring for VA enrollees with COVID-19 were in rural areas.
    Date: May 30, 2023
  • Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic
    This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level.
    Date: March 7, 2023
  • Timeliness of VA Purchased Community Primary Care Did Not Improve Following Early Expansion Under MISSION Act
    This study examined whether early Community Care Network (CCN) implementation impacted community primary care (PC) appointment wait times. Findings showed that expanded contracting with community providers and new provider network adequacy standards implemented through CCNs did not, in early stages, improve the timeliness of community primary care for Veterans. Wait times increased sharply for both CCN and comparison appointments after CCN implementation, ranging from approximately 30 to 40 days, which is beyond VA’s new urban and rural network adequacy wait-time standard for community care.
    Date: October 28, 2022
  • New Metric Determines Adequacy of VA Primary Care Staffing
    This study created a primary care provider (PCP) staffing measure using clinic-level provider FTE and number of assigned patients to identify primary care (PC) clinics at risk of insufficient staffing and describe rural-urban staffing variation. Using this metric, over the 3.5-year study period at 916 clinics, 38 (4%) were always under-staffed, 21 (2%) were always marginally staffed, and 200 (22%) were always fully staffed. At the end of the study period (March 2021), 351 PC clinics (39%) were not fully staffed and 179 of these clinics (51%) had a gap of at least 0.5 Advanced Practice Provider FTE, representing a potential minimum threshold for hiring a new provider. But 559 clinics were fully staffed with excess clinic capacity of 11-15%. Depending how FTE is distributed (e.g., across clinics vs. within each clinic) and the provider type, 228 to 521 PCP FTE are needed to fully staff all PC clinics as of March 2021. This represents a 4-8% provider staffing deficit. Over the entire study period, rural clinics, on average, were under-staffed for 21% of months compared to 14% of months for urban clinics, a 50% higher rate. The gap staffing metric may be a beneficial tool to identify PC clinics that are persistently over- or under-staffed, facilitating strategic workforce planning and allowing better distribution of provider FTE to address patient care needs.
    Date: August 4, 2022
  • Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior
    This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a suicide-related ED visit, and a 22% reduction in the likelihood of suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via telehealth and for preventing suicides among rural residents.
    Date: April 6, 2022
  • Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans
    This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.
    Date: October 21, 2021
  • Veterans Do Not Always Receive Appropriate Continuation of OUD Medications During Surgical Hospitalizations
    This study sought to describe practice patterns of perioperative buprenorphine use within VA – and patient outcomes up to 12 months following surgery. Findings showed that the majority of VA surgical patients in this study who received buprenorphine for opioid use disorder experienced a dose hold at some point during the perioperative period despite a trend in clinical guidelines recommending buprenorphine continuation: 40% of Veterans were instructed to hold buprenorphine prior to surgery, more than 60% did not receive buprenorphine on the day of surgery, and 55% did not receive a buprenorphine dose on the day following surgery. Homelessness/housing insecurity and rural residence were the only two predictors explored in this study that were associated with decreased likelihood of a perioperative buprenorphine dose hold. Discontinuation of buprenorphine following surgery also was relatively common. One month following surgery,13% of Veterans had no active buprenorphine prescription, increasing to 25% and 33% at 6- and 12-months post-surgery, respectively. As holding buprenorphine perioperatively does not align with emerging clinical recommendations – and carries significant risks – educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care before and after surgery.
    Date: September 20, 2021
  • Treatment Disparities for Vulnerable VA Patient Populations with Opioid Use Disorder
    This study examined the association between vulnerable populations, facility characteristics, and receipt of medications for opioid use disorder (OUD). Findings showed that since the last national study of VA patients (using FY2012 data), the prevalence of receipt of medications for OUD increased overall from 33% to 41%; however, vulnerable patient populations – including women, older, Black, rural, homeless, and justice-involved Veterans – had lower odds of receiving medications for OUD than their non-vulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with OUD, and lower odds of receiving medications at facilities in the Southern region of the United States compared to the Northeast. The prevalence of OUD was notably higher among homeless compared to housed Veterans (10% vs 2%), and justice-involved compared to non-justice-involved Veterans (10% vs 2%).
    Date: August 18, 2020
  • Patient Satisfaction with VA Virtual Care Delivered by Video-Enabled Tablet
    In 2016, VA’s Offices of Rural Health and Connected Care developed a pilot initiative to distribute video-enabled tablets to Veterans who did not have the necessary technology and who had a geographic, clinical, or social barrier to in-person healthcare. During this pilot, 5,000 tablets were distributed to 6,745 patients at 86 VA facilities, with approximately half of the tablet recipients living in rural areas. To help inform optimal tablet distribution and technical support, investigators evaluated patient experiences with tablets through baseline and follow-up surveys. Many recipients of VA-issued tablets reported that video care is equivalent to or preferred to in-person care. Among follow-up survey respondents, 32% of tablet recipients indicated that they would prefer to conduct their future VA appointments by video; 32% indicated they would prefer these visits in person; and 36% indicated their preference was “about the same.” The most common barriers to in person care were travel time (66%), travel cost (55%), health conditions (54%), bad weather (57%), and feeling uncomfortable or uneasy at VA (33%). Between baseline and follow-up surveys, there were statistically significant increases in patient satisfaction regarding overall VA care, as well as primary care and mental healthcare. Satisfaction regarding technology and technical assistance also was high: 86% agreed or strongly agreed with statements regarding the ease of using the equipment, receiving help needed to learn the technology (84%), and that it was easy to ask questions (88%) and understand instructions (87%). Strong satisfaction ratings for tablets and the fact that characteristics such as age, health literacy, and prior technology use were not significantly associated with tablet preference suggest that engagement in video-based care is possible for many types of patients, including those often considered part of the “digital divide.”
    Date: April 15, 2020
  • Significant Duplicative Spending on Coronary Revascularization Procedures among VA and Medicare Dual Enrollees
    This study sought to describe where dually-enrolled VA-Medicare Advantage (MA) Veterans receive coronary revascularization and the associated costs. Findings showed that a significant share of VA healthcare users, concurrently enrolled in a Medicare Advantage plan, received coronary revascularization procedures through VA, incurring significant duplicative federal healthcare spending of nearly $215 million from 2010 through 2013. Over the study period, 22% of patients received either CABG or PCI through VA, 75% through MA, and 3% through both payers. Among this cohort, younger, non-white Veterans living in urban and rural counties were more likely to receive CABG or PCI through VA, whereas distance to a VA hospital did not independently influence the choice of VA versus MA for coronary revascularization. Findings suggest that the growing number of Medicare beneficiaries opting into Medicare Advantage is likely to lead to an increase in duplicative billing.
    Date: April 6, 2020
  • Embedding Social Workers in VA Primary Care Teams Reduces Emergency Department Visits
    In 2016, VA’s National Social Work Program initiated the Social Work Patient Aligned Care Team (PACT) Staffing Program, which provided funding from the Office of Rural Health for PACT social workers to serve Veterans living in rural areas. This study evaluated the impact of this program on Veterans who had at least one primary care visit between October 2016 and June 2019 at one of 93 VA outpatient sites. Findings showed that addressing Veterans’ social determinants of health is an integral component of delivering effective primary care. For example, the percentage of ED visits for Veterans in the study cohort decreased after a PACT social worker was assigned to the primary care clinic. Among high-risk patients there was a 3% decrease in Veterans who had ED visits and a 4% decrease in the number of Veterans who had acute hospital admissions. This translates to an expected decrease of about 8,000 fewer VA-paid ED visits per year after the deployment of additional social workers, and as many as 9,000 fewer hospital days. The program increased social work visits by 33% in the full cohort, and by 29% in the high-risk group.
    Date: April 1, 2020
  • All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
    After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
    Date: January 31, 2020
  • Rural and Western Region Veterans Prescribed More Opioids Than Urban, Other Regions
    This study sought to characterize regional variation in opioid prescribing across VA and examine prescribing differences between rural and urban Veterans. Findings showed substantial rural-urban variation in VA opioid prescribing, with rural Veterans receiving over 30% more opioids than their urban counterparts, with most of the difference attributable to long-term use. Utilization was lowest in the Northeast and highest in the West. Mean days’ supply dispensed at initiation was higher for rural veterans (15 vs. 13) and the proportion prescribed an initial 30 days’ supply was 23% for rural vs. 19% for urban Veterans. The prescribing gap between urban and rural Veterans in the South was 33% vs. 13% in the Northeast, and similar in the West and Midwest. Higher rates of opioid prescribing among rural compared to urban Veterans are driven mostly by higher rates of long-term use, indicating a need for interventions to improve access to non-pharmacologic treatment for chronic pain among rural Veterans.
    Date: May 21, 2019
  • Increase in Travel Reimbursement Increases Use of VA Outpatient Services
    The extent to which VA and non-VA care are substitutes or complements for each other will dictate how the demand for VA care will change as Veterans make use of the Choice Program. This study used another VA policy change – one that increased the reimbursement rate that eligible Veterans receive for VA healthcare-related travel – to understand the use of VA and Medicare services among Medicare-enrolled Veterans. This analysis allowed investigators to determine whether the increased VA utilization due to the travel reimbursement rate increase was accompanied by a decrease in non-VA utilization, indicating that the two were substitutes, or if there was also an increase in non-VA utilization, which would indicate that the two were complements. Findings showed that compared to those not eligible to receive travel reimbursement, Veterans who were eligible for reimbursement had significantly more VA outpatient encounters following the reimbursement rate increases. This was true both for Medicare-enrolled Veterans over and under age 65. Veterans living in rural areas in both age groups significantly decreased their use of non-VA outpatient care following the travel reimbursement increase, suggesting that VA outpatient care may be a substitute for Medicare outpatient care for Medicare-enrolled Veterans in both age groups living in rural areas.
    Date: July 1, 2018
  • Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers
    This study examined the potential impacts of reforms to improve access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop telehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers.
    Date: May 29, 2018
  • Assessing Expansion of VA’s Home-Based Primary Care Program for American-Indian Veteran Patient Population
    VA provides home-based primary care (HBPC) in rural communities with American Indian reservations, where prospective patients may qualify for healthcare from VA, Medicare (CMS), and/or the Indian Health Service (IHS). This multi-site study of the effectiveness of HBPC expansion to these rural areas also describes the characteristics of patients who meet the requirements for admission to rural HBPC. Findings showed that expansion of the HBPC program was effective in introducing non-institutional home-based primary medical care to populations residing in American Indian reservations and other rural communities. Among HBPC users, VA enrollment increased by 22%. Results suggest opportunities to identify new clients for services that support aging in rural settings.
    Date: April 1, 2018
  • Veterans with Cancer Received Higher Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
    This study evaluated the quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
    Date: January 1, 2018
  • Medical Care Supplement Features Articles by VA Researchers on Improving the Quality and Equity of Health and Healthcare
    In 2016, HSR&D’s Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) hosted a state-of-the-science conference. This field-based meeting to “Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System” brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance the implementation of evidence-based interventions to improve the quality and equity of health and healthcare. The conference focused on three specific vulnerable Veteran populations: racial and ethnic minorities, homeless Veterans, and Veterans from the LGBT community. This supplement features several articles that emanated from this meeting.
    Date: September 1, 2017
  • Substantial Portion of Elderly Veterans Receive Medications from Medicare Part D-Reimbursed Pharmacies – Either Alone or in Conjunction with VA Pharmacies
    This study examined patterns of medication acquisition from VA and Medicare Part D-reimbursed pharmacies following the implementation of Part D. Findings showed that nearly one-third of VA healthcare users received medications from Part D-reimbursed pharmacies, either alone or in combination with VA pharmacies. Veterans who lived in rural areas, were not black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual (i.e., both VA and Part D) pharmacy users or Part D-reimbursed only pharmacy users compared to other Veterans. Among dual pharmacy users, more than half of the Veterans received medications from the same drug class from both VA and Part D-reimbursed pharmacies that overlapped by more than seven days. Results highlight the clinical importance of assessing medications from VA and non-VA sources. At particular risk for suboptimal medication reconciliation are those Veterans who receive care within VA only or from both VA and Medicare outpatient clinics, but who solely obtain their medications from non-VA pharmacies.
    Date: February 1, 2017
  • Evaluating Patient-Mediated Health Information Exchange
    In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information.
    Date: October 11, 2016
  • More than Half of Privately Insured Veterans Younger than 65 Years of Age Access both VA and Non-VA Healthcare
    This study sought to quantify use of VA and non-VA care among working-age Veterans with private insurance by linking VA data to private health insurance plan (PHIP) data. Findings showed that more than half (54%) of Veterans younger than 65 who were enrolled in both VA and private health insurance plans accessed both healthcare systems; 39% used non-VA healthcare only, while 5% used VA healthcare only. Dual system users had the lowest percentage of Veterans under age 40 (15%) and the highest percentage of Veterans over age 50 (71%), while VA-only users had the highest percentage of Veterans under age 40 (22%) and the lowest percentage of Veterans over age 50 (61%). Dual system users also had the highest proportion of Veterans residing in rural settings (61%). VA reliance was 33% for outpatient care, 14% for inpatient care, and 40% for pharmacy. Findings suggest that care coordination efforts for Veterans across age groups should include privately insured Veterans under age 65 in order to ensure safe and coordinated care.
    Date: September 1, 2016
  • Telemedicine-Delivered Psychotherapy for Older Veterans with Depression as Effective as In-Person Psychotherapy
    This study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Findings showed that telemedicine-delivered psychotherapy for older Veterans with major depression produced outcomes that were no worse than in-person treatment delivery. Treatment response did not differ significantly between the telemedicine and same-room therapy groups on any of the instruments used. A high proportion of Veterans were rural residents (71%) and average session attendance was high (81% of Veterans in the telemedicine group completed all 8 sessions as did 79% of Veterans in the same-room group).
    Date: August 1, 2015
  • Early Discontinuation and Sub-Optimal Dosing for Drug to Treat Sleep Disorders Associated with PTSD
    This study sought to identify a cohort of Veterans with PTSD initiating prazosin, and then characterize the typical duration of use and dosing patterns over the first year following initiation. Findings showed that approximately 20% of Veterans never refilled the initial prescription, while only 38% of Veterans continued the medication for at least one year. Veterans taking serotonin- reuptake inhibitor (SSRIs) or serotonin-norepinephrine reuptake inhibitor (SNRIs) antidepressants were more likely to maintain prazosin treatment for one year (41%) compared to non-users (33%). One-year prazosin persistence also increased with the patient’s age and number of concurrent medications. Prazosin persistence was not associated with gender, or rural residence. The mean maximum dose of prazosin reached in the first year of treatment was 3.6 mg/day, with only 15% of Veterans reaching the minimum guideline recommended dose of 6 mg/day. Research is needed to identify what factors inhibit patients from reaching the minimum recommended target dose and what characteristics are associated with prazosin response.
    Date: May 1, 2015
  • Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
    This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
    Date: December 3, 2014
  • Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings
    This trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Findings showed that telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of Veterans randomized to the Telemedicine Outreach for PTSD (TOP) intervention received Cognitive Processing Therapy (CPT) compared to 12% of Veterans who were randomized to usual care. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD). The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
    Date: November 19, 2014
  • Poor Communication between VA and Non-VA Primary Care Providers co-Managing Rural Veterans
    This study examined the perspectives of community-based, non-VA primary care providers (PCPs) regarding their experiences co-managing Veterans with VA providers. Findings showed that communication with VA was viewed as poor by 66% of non-VA primary care providers, and many non-VA PCPs (42%) believed this led to poor patient outcomes. They also felt that they interacted with VA as a system rather than with individual VA providers. While the majority of non-VA providers were dissatisfied with their communication with VA providers, this did not translate into a negative opinion of VA healthcare; most felt the overall quality of VA care was high. Veterans were identified as the main medium for information transfer between VA and non-VA providers, which was viewed as undesirable. When non-VA PCPs were asked about their ideal method of communication, they most commonly identified electronic health records and fax that would occur automatically. They also identified the need for a VA point of contact to triage direct calls from non-VA providers.
    Date: November 1, 2014
  • PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment
    This study is the first randomized controlled trial to compare the efficacy of delivering “cognitive processing therapy-cognitive only” (CPT-C) via video-teleconferencing (VTC) to in-person delivery among a sample of rural Veterans. Findings showed that the use of clinical video-conferencing services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was as effective as face-to-face treatment. Significant reductions in PTSD symptoms were identified at post-treatment and 3- and 6-month follow-ups. High levels of therapeutic alliance, treatment compliance, and satisfaction, and moderate levels of treatment expectancies were reported, with no differences between groups. VTC technology evidenced very few disruptions, and no sessions were canceled due to technological difficulties. There were no adverse events associated with delivering CPT-C through videoconferencing.
    Date: May 1, 2014
  • Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
    This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
    Date: December 16, 2013
  • Home-Based Colorectal Cancer Screening Significantly Improves Screening Rates among Overdue Veterans in a Rural State
    This study sought to determine whether a simple 1-step mailing of a fecal immunochemical test (FIT) accompanied by educational materials would improve colorectal cancer (CRC) screening rates in Veterans who were overdue compared to Veterans who received educational materials only and to Veterans who received no mailings. Findings showed that mailing FITs and educational materials to Veterans overdue for CRC screening resulted in significantly higher screening rates than usual care or educational materials alone. At six months, 21% of Veterans in the FIT group had received CRC screening by any method compared to 6% in the educational materials-only group and 6% in the usual care group. Among respondents eligible for FIT, 90% completed and returned a FIT. Among Veterans in the FIT group, 8 (12%) received positive results. Of these Veterans, 6 received a colonoscopy, while the other 2 were advised against the procedure by their physicians due to terminal conditions. The overwhelming reason for not having at-home testing was that it was not recommended by their provider (62%).
    Date: October 25, 2013
  • Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care
    This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
    Date: July 30, 2013
  • Veterans Receiving Primary Care in CBOCs Less Likely to Receive Several Types of Colon Cancer Screening Tests
    This study evaluated differences in the choice of colorectal cancer (CRC) screening test in Veterans receiving primary care at community-based outpatient clinics (CBOCs) and at VAMCs. Findings showed that Veterans receiving care at a CBOC were less likely to receive colonoscopy, sigmoidoscopy and double-contrast barium enema than Veterans receiving care at VAMCs, even after adjusting for rural location, distance from a parent VAMC, and other patient demographic and clinical characteristics. Lower rates of screening procedures were not offset by higher utilization of fecal occult blood tests, and were consistent in Veterans at average and high risk for CRC. The difference in the use of colonoscopy in CBOCs and VAMCs was larger for Veterans 65 years or older than for patients less than 65 years, suggesting that older Veterans who receive primary care through CBOCs may use more CRC screening services outside VA relative to those under 65. These findings provide indirect evidence of the importance of examining data from non-VA providers when making judgments about adherence to VA performance measures.
    Date: July 5, 2013
  • Patient and Facility Characteristics Associated with Prescribing Benzodiazepines for Veterans with PTSD
    This study examined patient and facility-level correlates of benzodiazepine prescribing among Veterans with PTSD in the VA healthcare system. Findings showed that 30% of the Veterans in this study received a benzodiazepine. The majority (94%) of Veterans with any benzodiazepine use received = 30 days’ supply, and approximately two-thirds received more than 90 days of continuous benzodiazepine treatment. Among patient characteristics predicting benzodiazepine use, the largest odds ratios were observed for anxiety disorder comorbidity. Other characteristics associated with increased risk for benzodiazepine exposure included female gender, age = 30 years, rural residence, service connection = 50%, Vietnam era service, and duration of PTSD diagnosis. However, case-mix adjustment for these variables accounted for <1% of the variation in benzodiazepine prescribing across VA facilities. Main study findings were corroborated in replication analyses using data from two additional years (FY2003 and FY2006).The wide variation in facility-level benzodiazepine prescribing across VA cannot be explained by differences in patient characteristics across facilities.
    Date: February 1, 2013
  • Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
    This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher, quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
    Date: January 1, 2013
  • Telemental Health Expands in VA between 2006-2010
    This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare.
    Date: November 1, 2012
  • VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
    Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
    Date: April 1, 2012
  • Distance Most Important Barrier for Rural-Residing Veterans Seeking Healthcare
    This study of rural Veterans, providers, and staff examined the impact of travel distance on the use of VA healthcare services, satisfaction, and impact on care delivery. Findings showed that distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. The average one-way distance that Veterans traveled to a VA primary care clinic was 44.5 miles. The most common types of distance barriers discussed pertained to patient health, functioning, and financial or time resources. Other barriers frequently cited included challenges associated with travel, such as limited transportation and cost/expense. Veterans perceived the same travel distance as more burdensome when seeking care for regular services available locally (e.g. laboratory, podiatry), when compared with specialty care (e.g., cardiology, neurology). Many older Veterans who were able to drive viewed distance more as a ‘way of life’ than a ‘barrier.’ However, given that 44% of Veterans are >65 years old, travel distance is likely to become increasingly salient as a barrier in this aging population.
    Date: November 1, 2011
  • Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
    The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
    Date: November 1, 2011
  • Survey-based vs. Chart-based Screening Yields Significantly Higher Rates of Depression among Veterans in Primary Care
    This study sought to characterize the yield of practice-based screening in 10 diverse VA primary care clinics ( rural and urban), as well as the care needs of Veterans assessed as having depression. Findings showed that practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. Practice-wide depression screening yielded 20% positive depression screens and 12% probable major depression. This is substantially higher than most previously reported VA rates. In addition, comorbid medical and mental illness were highly prevalent.
    Date: October 6, 2011
  • Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality
    This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume.
    Date: July 19, 2011
  • VHA Policymakers May Need to Consider Additional Classification Schemes when Planning Care for “ Rural” Veterans
    To better understand the issues confronting Veterans living in rural settings, VHA developed a three-category classification system that designates locations throughout the U.S. as Urban, Rural, or Highly Rural. To understand the policy implications of the VA classification system, this study compared VA’s categories to three Office of Management and Budget (OMB) and four Rural-Urban Commuting Area (RUCA, developed by the University of Washington and the USDA) geographical categories. Findings show that although the three classification schemes differ considerably in the number of VHA healthcare enrollees designated as Rural residents, they all show that the proportions of rural Veterans among enrollees are substantial. VHA’s Rural category (36% of its enrollees) is broadly defined and includes up to 3 to 5 times the enrollees included in the middle RUCA or OMB categories. VHA’s Highly Rural and Urban categories are defined more narrowly than in the other schemes, suggesting that VHA’s categories may more accurately reflect specifically urban or remotely rural populations. Of Veterans enrolled in VA healthcare, roughly 1 in 60 is a Highly Rural resident. If policymakers rely solely on either the RUCA or OMB category scheme, they might conclude that access standards have been met for the majority of VHA enrollees. However, the VHA scheme indicates that access standards have not been met for Veterans living in highly rural settings. Thus, authors suggest that policymakers supplement analyses of Rural Veterans’ healthcare needs with more detailed breakdowns from other classification systems.
    Date: September 1, 2010
  • Using One Classification System for Estimates of Urban/ Rural Impact on AMI Outcomes among Veterans May Not Be Adequate
    This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban- rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban- rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate.
    Date: September 1, 2010
  • Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
    Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
    Date: May 11, 2010
  • Rural-Dwelling VA Patients have Worse Physical Health but Better Mental Health than Urban-Dwelling Counterparts
    Rural Veterans reported worse physical health but better mental health when compared to their urban counterparts, and these differences persisted across the four survey years. The differences were substantial and statistically significant and persisted after correcting for age, gender, marital and employment status, educational level, and local income level.
    Date: March 1, 2010
  • Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
    Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
    Date: January 26, 2010
  • Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
    Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
    Date: January 1, 2010
  • Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
    Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of quality assessment.
    Date: January 1, 2009
  • Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals
    Regardless of where they live ( rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas.
    Date: October 1, 2008

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