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DHI 07-065 – HSR&D Study

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DHI 07-065
Women Veterans Cohort Study
Cynthia A. Brandt MD MPH
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: November 2007 - October 2012

BACKGROUND/RATIONALE:
The proportion of women in the military, their roles, and their exposure to combat changed dramatically during Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND). The impact of these changes on women's health outcomes, health care needs, and utilization remain largely unknown.

OBJECTIVE(S):
The primary objective of our project was to identify important factors of gender associated disparities in health care utilization and outcomes among OEF/OIF/OND Veterans receiving care in the VA system. The long range goal of WVCS was to develop a greater understanding of the impact of military service on women's lives to improve preventive and overall VHA healthcare delivery.


METHODS:
We created an electronic medical record (EMR) cohort of male and female Veterans from the OEF/OIF/OND roster and VA electronic administrative and clinical data, and supplemented the data in this cohort with prospective patient-collected survey. As of October 2012, the EMR-based cohort includes administrative and clinical data from the Corporate Data Warehouse (CDW) for over 900,000 Veterans. The prospective survey has been completed by 693 Veterans out of the 776 Veterans enrolled, with 522 follow-up one and 214 follow-up two completed.

FINDINGS/RESULTS:
Through the use of EMR and survey cohorts we have addressed medical and mental health outcomes, utilization, costs, and other issues including substance abuse and homelessness among women Veterans. The first overall paper on the cohort reported on burden of illness the first year home and showed that female Veterans were slightly younger (mean age, 30 years vs. 32 for men; p <.0001), twice as likely to be African American (30% vs. 15%; p <.0001), and less likely to be married (32% vs. 49%; p < .0001). Women had more visits to primary care (2.6 vs. 2.0; p < .001) and mental health (4.0 vs. 3.6; p < .001) clinics and had higher use of community care outside the VA (14% vs. 10%; p < .001). After adjustment, women were more likely to have skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have posttraumatic stress disorder. Our initial paper looking at the cost and utilization differences in the first year post last deployment showed female Veterans have higher pharmacy and outpatient costs than male Veterans. We also published findings related to pain and showed that among Veterans with pain, female Veterans were more likely to report moderate to severe pain. Additionally, we found that females were more likely to have back pain, joint pain or a musculoskeletal condition in the first seven years after deployment. Other medical outcomes were investigated, including cardiovascular risk. Several analyses have shown differences in female and male Veterans in rates of smoking, obesity; and trajectories of BMI found that female Veterans were more likely to be associated with groups characterize by lower post-deployment BMIs. There were also significant findings on reproductive health care. One publication showed 32% of Veterans with a pregnancy and 21% of those without received one or more mental health diagnoses, and pregnant Veterans in VA care were more than twice as likely as non-pregnant women Veterans to experience depression, PTSD, and anxiety disorders. Females also appear to utilize VA facilities for common gender-specific conditions, but rely more heavily on fee basis care for specialized gender-specific health needs (paper under review). We used data from the prospective cohort (WVCS 1 survey) to assess contraceptive use. We presented data that showed 57% of females reported using prescription birth control or condom while 22% reported use of a medication that could cause a birth defect.
Three other recent findings were: 1) the comparison of usage of VHA homeless service programs by Veterans of OEF/OIF/OND showed about 2.0% were identified as having using VA homeless services with a median time to use of VA homeless services of 671 and 680 days for women and men, respectively (p=0.43); 2) a report on how women Veterans cope with combat and military sexual trauma; and 3) a paper reporting gender differences in the correlates of hazardous drinking found gender differences in the association between hazardous drinking and lifetime trauma history, PTSD symptoms, and interpersonal conflict, which may have important implications for the treatment of alcohol problems in men and women Veterans.
Finally, four papers have recently been accepted for publication: two papers on identifying use in women Veterans using natural language processing in medical record free text; a third is on counseling of female Veterans about the risks of medication-induced birth defects; and the fourth is on VA healthcare utilization among lesbian and bisexual female OEF/OIF Veterans.

IMPACT:
WVCS has contributed significantly to the growing literature on women Veterans, their healthcare outcomes, costs, needs, and experiences with VA care. The finding that enrolled female Veterans have higher pharmacy and outpatient costs than male Veterans, is concurrent with other studies of gender related costs of care, and can impact planning and policy related to resource allocation. Additionally, WVCS has provided a foundation for a growing literature related to pain and musculoskeletal conditions in women Veterans that has sparked a national discussion about treatment and prevention of these conditions. The WVCS findings on pregnancy and mental health in women Veterans impacted national policy requiring maternity care coordination and influenced the development of a national initiative on reproductive mental health. We hope to use the WVCS cohort to continue a longitudinal analysis of gender differences in risk for chronic disease (pain, cardiovascular and mental health conditions) after deployment of OEF/OIF/OND.

PUBLICATIONS:

Journal Articles

  1. Burg MM, Brandt C, Buta E, Schwartz J, Bathulapalli H, Dziura J, Edmondson DE, Haskell S. Risk for Incident Hypertension Associated With Posttraumatic Stress Disorder in Military Veterans and the Effect of Posttraumatic Stress Disorder Treatment. Psychosomatic medicine. 2017 Feb 1; 79(2):181-188.
  2. Higgins DM, Kerns RD, Brandt CA, Haskell SG, Bathulapalli H, Gilliam W, Goulet JL. Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/operation New Dawn veterans. Pain medicine (Malden, Mass.). 2014 May 1; 15(5):782-90.
  3. Seng EK, Driscoll MA, Brandt CA, Bathulapalli H, Goulet J, Silliker N, Kerns RD, Haskell SG. Prescription headache medication in OEF/OIF veterans: results from the Women Veterans Cohort Study. Headache. 2013 Sep 1; 53(8):1312-22.
  4. Womack JA, Scotch M, Leung SN, Skanderson M, Bathulapalli H, Haskell SG, Brandt CA. Use of structured and unstructured data to identify contraceptive use in women veterans. Perspectives in health information management / AHIMA, American Health Information Management Association. 2013 Jul 1; 10:1e.
  5. Scott JC, Pietrzak RH, Mattocks K, Southwick SM, Brandt C, Haskell S. Gender differences in the correlates of hazardous drinking among Iraq and Afghanistan veterans. Drug and Alcohol Dependence. 2013 Jan 1; 127(1-3):15-22.
  6. Blackstock OJ, Haskell SG, Brandt CA, Desai RA. Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan veterans. Medical care. 2012 Apr 1; 50(4):347-52.
  7. Haskell SG, Ning Y, Krebs E, Goulet J, Mattocks K, Kerns R, Brandt C. Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. The Clinical journal of pain. 2012 Feb 1; 28(2):163-7.
  8. Mattocks KM, Haskell SG, Krebs EE, Justice AC, Yano EM, Brandt C. Women at war: understanding how women veterans cope with combat and military sexual trauma. Social science & medicine (1982). 2012 Feb 1; 74(4):537-45.
  9. Schonberger RB, Burg MM, Holt N, Lukens CL, Dai F, Brandt C. The relationship between preoperative and primary care blood pressure among veterans presenting from home for surgery: is there evidence for anesthesiologist-initiated blood pressure referral? Anesthesia and analgesia. 2012 Jan 1; 114(1):205-14.
  10. Rosenberger PH, Ning Y, Brandt C, Allore H, Haskell S. BMI trajectory groups in veterans of the Iraq and Afghanistan wars. Preventive medicine. 2011 Sep 1; 53(3):149-54.
  11. Leslie DL, Goulet J, Skanderson M, Mattocks K, Haskell S, Brandt C. VA health care utilization and costs among male and female veterans in the year after service in Afghanistan and Iraq. Military medicine. 2011 Mar 1; 176(3):265-9.
  12. Mattocks KM, Nikolajski C, Haskell S, Brandt C, McCall-Hosenfeld J, Yano E, Pham T, Borrero S. Women veterans' reproductive health preferences and experiences: a focus group analysis. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Mar 1; 21(2):124-9.
  13. Haskell SG, Mattocks K, Goulet JL, Krebs EE, Skanderson M, Leslie D, Justice AC, Yano EM, Brandt C. The burden of illness in the first year home: do male and female VA users differ in health conditions and healthcare utilization. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2011 Jan 1; 21(1):92-7.
  14. Mattocks KM, Skanderson M, Goulet JL, Brandt C, Womack J, Krebs E, Desai R, Justice A, Yano E, Haskell S. Pregnancy and mental health among women veterans returning from Iraq and Afghanistan. Journal of women's health. 2010 Dec 1; 19(12):2159-66.
  15. Duggal M, Goulet JL, Womack J, Gordon K, Mattocks K, Haskell SG, Justice AC, Brandt CA. Comparison of outpatient health care utilization among returning women and men veterans from Afghanistan and Iraq. BMC health services research. 2010 Jun 22; 10:175.
  16. Haskell SG, Gordon KS, Mattocks K, Duggal M, Erdos J, Justice A, Brandt CA. Gender differences in rates of depression, PTSD, pain, obesity, and military sexual trauma among Connecticut War Veterans of Iraq and Afghanistan. Journal of women's health. 2010 Feb 1; 19(2):267-71.
  17. Haskell SG, Brandt CA, Krebs EE, Skanderson M, Kerns RD, Goulet JL. Pain among Veterans of Operations Enduring Freedom and Iraqi Freedom: do women and men differ? Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1167-73.
CYBR

  1. Haskell S. Pain in Women Veterans. [Cyberseminar]. 2012 Mar 14.
Conference Presentations

  1. Higgins DM, Goulet JL, Heapy AA, Kerns RD, Brandt CA, Haskell S. Trauma type, social support, and pain in Veterans: Does gender matter? Poster session presented at: American Pain Society Annual Meeting; 2014 May 1; Tampa, FL.
  2. Esiobu N, Bathulapalli H, Edelman EJ, Erdos JJ, Gordon K, Goulet JL, Haskell S, Justice AC, Brandt CA. Gender stratified factors associated with Major Depression among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans seeking VA Health Care. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2012 Oct 29; San Francisco, CA.
  3. Blackstock O, Brandt CA, Haskell S, Desai RA. Gender and the Risk of Homelessness among Iraq/Afghanistan Veterans. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  4. Rosenberger PH, Mattocks KM, Brandt CA, Haskell S. Obesity and Health Comorbidities in OEF/OIF Veterans: Early Associations. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  5. Womack JA, Haskell S, Mattocks KM, Brandt CA. Contraceptive Use Among Women OEF/OIF Veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  6. Blackstock O, Brandt CA, Haskell S, Desai RA. Gender and the Risk of Homelessness among Iraq/Afghanistan Veterans. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ.
  7. Blackstock O, Brandt CA, Haskell S, Desai RA. Gender and the Risk of Homelessness among Iraq/Afghanistan Veterans. Paper presented at: Society of General Internal Medicine New England Regional Annual Meeting; 2011 Mar 4; Boston, MA.
  8. Goulet JL, Brandt CA, Desai RA, Haskell S. Gender differences in patterns of comorbidity with PTSD among OEF/OIF Veterans. Paper presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
  9. Ning Y, Goulet JL, Brandt CA. Accounting for the hierarchical structure in Veterans Administration datasets: differences in mental health service utilization between men and women Veterans. Paper presented at: VA Women's Health Research Conference; 2010 Jul 14; Arlington, VA.
  10. Brandt CA, Haskell S, Goulet JL, skanderson M, Krebs E. Smoking Status in OEF/OIF Veterans Enrolled in VHA. Poster session presented at: VA Women's Health Research Conference; 2010 Jul 2; Washington, DC.
  11. Rosenberger PH, Brandt CA, Nong Y, Allore H. Gender Differences in Post Deployment Body Mass Index (BMI) Change in OEF/OIF Veterans. Paper presented at: VA Women's Health Research Conference; 2010 Jul 2; Arlington, VA.
  12. Mattocks KM, Nikoljaski C, Haskell S, Brandt CA, Yano E, Borrero S. Understanding Women Veterans’ Use, and Unmet Needs, for Reproductive Health Services in the Veterans Administration (VA). Paper presented at: VA Women's Health Research Conference; 2010 Jul 1; Washington, DC.
  13. Mattocks KM, Nikoljaski C, Haskell S, Brandt CA, Yano E, Borrero S. Understanding Women Veterans’ Use, and Unmet Needs, for Reproductive Health Services in the Veterans Administration (VA). Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.
  14. Mattocks KM, Nikoljaski C, Haskell S, Brandt CA, Yano E, Borrero S. Understanding Women Veterans’ Use, and Unmet Needs, for Reproductive Health Services in the Veterans Administration (VA). Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 30; Minneapolis, MN.
  15. Krebs E, Goulet JL, Brandt CA. Sex Differences in OEF/OIF Veterans. Paper presented at: VA Rehabilitation Research for Polytrauma, PTSD, and Pain (P3) Research Summit; 2009 Sep 29; New Haven, CT.
  16. Mattocks KM, Sindelar J, Brandt CA, Haskell S, Justice AC. Female Veterans Returning From Iraq and Afghanistan: Stress-Related Behaviors and Coping Mechanisms. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  17. Mattocks KM, Sindelar J, Brandt CA, Haskell S, Justice AC. Female Veterans Returning From Iraq and Afghanistan: Stress-Related Behaviors and Coping Mechanisms. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2008 Oct 27; San Diego, CA.
  18. Duggal M, Haskell S, Erdos JJ, Goulet JL, Justice AC, Brandt CA. Women returning from Operation Iraqi Freedom/Operation Enduring Freedom: Comparison of healthcare utilization among women & men veterans. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2007 Nov 7; Washington, DC.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems, Musculoskeletal Disorders, Other Conditions
DRE: Epidemiology, Treatment - Observational
Keywords: Utilization, Reintegration Post-Deployment, Women - or gender differences, Gender Differences, Operation Enduring Freedom, Operation Iraqi Freedom, Outcomes - Patient
MeSH Terms: none