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Director's Letter

David Atkins, M.D., M.P.H., Director, HSR&D

In his later years, Mark Twain advised “If you can’t get to 70 by a comfortable road, don’t go.” Comfortable journey or not, more and more Americans will live to 70 and beyond, and the critical question for American health care is how we will provide and pay for their health care needs. This problem is accelerated for VA, where the median age of the Veteran population is substantially older than that of the general population (64 years old vs. 44 years old)1 due to the large number of Vietnam and Korea Veterans served by VA. That figure alone—half of our patients are already 65 or older—highlights the importance of re­search on the health needs of older Veterans.

Equally compelling is the cost of care, which rises steadily with age. No single item is more expensive to VA than long-term care (i.e., nursing homes), which has risen to $6 billion a year. Even though VA provides nursing home care only to certain eligibility categories, within the next 5 years more than one million Veterans may be eligi­ble for nursing home care.2 We need continued research on non-in­stitutional alternatives for caring for older Veterans, including foster homes, technology-assisted services, and home-based primary care.

Second, patient-centered approaches to care are critically import­ant as people accumulate more health problems and as their years of remaining life decrease. Aggressive glucose control that makes sense in a 30-year-old diabetic may be dangerous in an 80-year-old with heart failure and mild cognitive impairment. This is also an area where VA has contributed important research, identifying spe­cific opportunities to reduce the burden of low value care on older Veterans.3 Nowhere is a personalized approach more important than at the end of life, where many patients may value maintaining quality of life more than extending their life. Here too VA has been a leader, both in the widescale provision of palliative care and in research documenting the benefits of palliative care for Veterans.

A final area where VA can lead in research on older patients is on the role of caregivers. The MISSION Act has expanded the number of caregivers eligible for some VA services, and HSR&D has estab­lished the Elizabeth Dole Center of Excellence for Veteran and Care­giver Research to facilitate research on innovation, implementation, and evaluation of best practices in supporting caregivers. Rigorous studies are needed to identify the best ways to train and support caregivers so that this new investment yields the hoped-for returns for the Veterans being cared for.

Just as we can’t personally escape the effects of aging, neither VA nor the United States can avoid the implications of an aging popu­lation on their health care systems. We will need the help of all the researchers we can get if we are going to meet this challenge.

David Atkins, MD, MPH, Director, HSR&D

  1. “Profile of Veterans: 2015, Data from the American Community Survey,” National Cen­ter for Veterans Analysis and Statistics, March 2017.
  2. “Wave of Elderly Veterans Creates Financial Worries for VA’s Nursing Home Services,” Military Times, February 20, 2019.
  3. Powell AA, Saini SD, Breitenstein MK et al. “Rates and Correlates of Potentially Inap­propriate Colorectal Cancer Screening in the Veterans Health Administration,” Journal of General Internal Medicine 2015; 30(6):732-41.


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