Zeber JE (Verdict), Copeland LA
(Verdict), McCarthy JF
(SMITREC), Bauer MS
(Providence VA), Kilbourne AM
Veterans with serious mental illness experience greater physical comorbidities than the general VA population. Access to medical services is complicated by care management occurring in psychiatric clinics not fully integrated with medical providers. Applying theoretical elements from the Andersen behavioral model, we examined associations between patient characteristics and self-reported problems accessing VA services.
435 patients with bipolar disorder were recruited (FY04-06) from the Continuous Improvement for Veterans in Care - Mood Disorders (CIVIC-MD) study. The validated Cunningham instrument measured perceived problems obtaining medical and psychiatric treatment, including difficulty finding appropriate treatment, receiving urgent care or specialty appointments, and foregoing services due to cost. Multivariable logistic regression predicting access problems controlled for: predisposing characteristics (demographics), enabling factors (transportation, homelessness), and need (currently hospitalized, bipolar symptoms, and substance abuse).
Compared to psychiatric care, patients reported greater difficulty accessing medical services, including specialist visits (19 percent versus 9 percent) and overall care when needed (17 percent versus 11 percent). Queried about specific problems, nearly 40% believed their illness needs were not serious or never pursued care. In multivariable models, individuals experiencing current bipolar symptoms perceived significantly worse access, including psychiatric specialty care and getting to medical appointments (ORs 2.43 and 2.01, respectively). Homeless veterans were three times more likely to report hospitalization barriers, plus greater difficulty accessing other treatment. Patients living alone experienced obstacles receiving any psychiatric (OR=2.58) or emergency medical care (OR=1.70). Conversely, older veterans reported better access, while minority patients generally encountered fewer problems than white patients.
Although veterans with bipolar disorder reported minimal difficulty accessing psychiatric treatment, 20 percent perceived problems obtaining medical services. Certain patients faced greater risks for encountering barriers coordinating care for their psychiatric and medical disorders, possibly interfering with treatment dynamics and jeopardizing clinical outcomes.
Access to needed care has long represented one of the VA’s strengths as a healthcare organization, yet perceptions of obtaining specialty or urgent medical care were less sanguine here. Recognizing how veterans with debilitating bipolar disorder perceive access to essential treatment may inform efforts to balance “competing medical demands” as patients work towards a more holistic pursuit of their recovery goals.