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1.  Mental illness and intensification of diabetes medications: an observational cohort study 
Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians’ decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.
In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003–2004, by MHC status.
Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0–14, 15–30 and 31–180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.
For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-458) contains supplementary material, which is available to authorized users.
PMCID: PMC4282515  PMID: 25339147
Psychiatric diagnosis; Diabetes mellitus/therapy; Health care delivery; Hypoglycemic agents/therapeutic use; Veterans; Health services research
2.  Receipt of Cervical Cancer Screening in Female Veterans: Impact of Posttraumatic Stress Disorder and Depression 
We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration (VHA) facilities between 2003 and 2007 and diagnosed with either: 1) posttraumatic stress disorder (PTSD); 2) depression; or 3) no psychiatric illness.
Our study featured a cross sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups.
Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD vs. 75% with depression vs. 75% without psychiatric illness were screened during the study observation period, P < .001. However, primary care use was associated with differential odds of screening in women with vs. without psychiatric illness (PTSD or depression), and findings held after even after adjustment for age, income and physical comorbidities (Wald Chi Square (2): 126.59, P < .0001). Specifically, among low users of primary care services, women PTSD or depression were more likely than those without psychiatric diagnoses to receive screening, but among high users of primary care services, they were less likely to receive screening.
Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with vs. without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive health care needs.
PMCID: PMC3704317  PMID: 23660429
cervical cancer screening; PTSD; depression; women; veterans
3.  Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):510-516.
While prior research characterizes women Veterans’ barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.
To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.
Cross-sectional, population-based 2008–2009 national telephone survey.
Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.
Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.
Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.
We found high VA attrition despite recent advances in VA care for women Veterans. Women’s attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.
PMCID: PMC3695263  PMID: 23807058
Veterans; women’s health; access to care; attrition
4.  The VA Women’s Health Practice-Based Research Network: Amplifying Women Veterans’ Voices in VA Research 
Journal of General Internal Medicine  2013;28(Suppl 2):504-509.
PMCID: PMC3695282  PMID: 23807057
women’s health; veterans; implementation research; quality improvement
5.  Medical Care Needs of Returning Veterans with PTSD: Their Other Burden 
There has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.
(1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD.
Cross-sectional study using existing databases (Fiscal Year 2006–2007).
Veterans Health Administration (VHA) patients nationally.
All 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC.
(1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality’s Clinical Classifications software framework).
The median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (p < 0.001), and for men was 5.0 versus 4.0 (p < 0.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC.
Burden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1497-4) contains supplementary material, which is available to authorized users.
PMCID: PMC3024098  PMID: 20853066
stress disorders; post-traumatic; veterans; Afghan campaign 2001-; Iraq War 2003-; women
6.  Toward a VA Women's Health Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S93-S101.
The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.
PMCID: PMC1513170  PMID: 16637953
women's health; research and development; research priorities; veterans; health care quality; access and evaluation
7.  Health Status Among 28,000 Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S40-S46.
Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.
To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.
Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.
Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).
In each age stratum (18 to 44, 45 to 64, and ≥65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged ≥65, mean MCS was better for women than men (49.3 vs 45.9, P<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.
Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.
PMCID: PMC1513164  PMID: 16637944
women's health; veterans; health status; quality of life; social support

Results 1-7 (7)