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FORUM - Translating research into quality health care for Veterans

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Commentary

Excellence in medical care is a product of research, innovation, and a passion for patient care. Nowhere is that more evident than at the U.S. Department of Veterans Affairs (VA). When a Veteran walks through the door of a VA medical facility it is our responsibility to deliver consistent, high-quality care—regardless of where the Veteran lives. However, in our routine efforts to identify new treatments and deliver existing ones, we sometimes overlook one of our most vulnerable populations: rural Veterans. Their advanced age, comorbidities, and combatrelated injuries complicate their care, and when compounded by provider shortages and the simple reality of distance to care, rural Veterans may find themselves at a disadvantage. To the extent that rural Veteran dependency on VA health care continues to grow relative to urban reliance, it is imperative that researchers strengthen their efforts to focus on Secretary Shulkin's priorities of access and modernization to give Veterans "true choice."

It is fair to say that the demographic and health-related characteristics that define "rural" may well be the harbinger for what is to come, and has lessons that will apply to an aging, medically complex, and increasingly reliant urban population. Rural to urban dissemination of research and innovation in health care is already happening in VA. The research community knows this, and the partnerships that the Office of Rural Health has with so many of their number bear witness. Nonetheless we need to do more.

The health care of America's 5.2 million rural Veterans is at risk. While 18 percent of the U.S. population lives in rural America, only nine percent of primary care physicians and seven percent of psychologists practice there. In addition, since 2010, 1.2 million rural patients lost access to their nearest hospital—30 of which closed in the past two years alone.

These constraints are amplified when we consider that over half of VA-enrolled rural Veterans are age 65-plus.1 According to the American Geriatric Society, those over age 65 use a disproportionate percentage of health care services and more than 80 percent require care for chronic conditions such as hypertension, arthritis, and heart disease. Aging rural Veterans, who need health care the most, have the hardest time accessing it.

The Office of Rural Health (ORH) was chartered by Congress in Public Law 109-461 "to work with all personnel and [VA] offices to develop, refine, and promulgate policies, best practices, lessons learned, and innovative and successful programs to improve care and services for [rural] Veterans..." As we look to solve future challenges, ORH has identified significant research gaps in the areas of transportation, rural women's health, and rural mental health services.

For many rural Veterans, simply getting to care is the challenge. An average rural Veteran travels over 30 minutes to receive primary care, and almost 90 minutes to receive specialized care—this is almost two times farther than the average urban Veteran. Telehealth technology alleviates some of the burden for technologically savvy rural Veterans, but long travel distances with limited public transit, income challenges, and inclement weather continue to significantly impact Veterans' ability to seek medical treatment. Further research to address, quite simply, "how do we get rural Veterans to treatment?" is not only necessary, but urgent.

Rural women Veterans face additional challenges because the VA system is underequipped to treat the 180,584 rural women enrolled in VA for care. A study of VA health care data found that rural residents are less likely to receive womenspecific health services, but more likely to use primary care, which suggests inequity in the availability of specialized services. ORH works with partners to develop programs that train practitioners on the specific health care needs of women from gynecological health to pregnancy issues to ovarian and cervical cancers. But more gender-specific condition research is needed to expand health care to our rural women Veterans.

If we ever hope to end the plague of Veteran suicide, we must invest more in research and development in rural suicide prevention. We know that of the 1.5 million Veterans that received mental health care in 2015, 435,000 lived in rural areas. These Veterans are more likely to experience depression than their urban counterparts, even after controlling for socioeconomic status and race.2 Additionally, rural residence by itself is a risk factor for depression among Veterans, even after controlling for mental health care accessibility.3 Recognizing these risks, ORH initiated research, funded telemental health hubs, and expanded mental health training for clergy based in rural areas in order to combat rates of rural Veteran suicide. To close this perilous health care access gap, more research and development into practical innovations for suicide prevention is critical.

Nobody knows Veterans better than VA. And while we offer care second to none, without new research and innovation, VA will fall short in caring for those who reside in rural communities. We need researchers' help in order to examine issues related to transportation, women's health and suicide prevention, but I have a larger ask. Simply, that more of you consider making rural health care an integral part of your models. Fully one-third of our enrolled population is rural, and rurality may provide unanticipated explanatory power for both rural and urban populations. The cost of inclusion will likely outweigh the unanticipated cost of exclusion, and will just as likely provide clues to the effective dissemination of innovation based on your research. Let's flip the urban to rural paradigm.

  1. Unless otherwise noted, all Veteran data are from the internal VHA sources at the VHA Support Services Center, 2015.
  2. Jawal LM, et al. "A Population-Based Cross Sectional Study Comparing Depression and Health Service Deficits Between Rural and Non-rural U.S. Military Veterans," Military Medicine, April 2015.
  3. Lutfiyya MN, et al. "Mental Health and Mental Health Care in Rural America: The Hope of Redesigned Primary Care," Disease-a-Month 2012; 58:629-38.

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