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.

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External Links for this Project

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PUBLICATIONS:

None at this time.

DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Health Systems Science, Musculoskeletal Disorders, Other Conditions
DRE: Epidemiology, Treatment - Observational
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, Women - or gender differences
MeSH Terms: none