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SHP 08-190 – HSR&D Study

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SHP 08-190
Rural/Urban Differences in Service Utilization Among OIF/OEF Veterans
Teresa J. Hudson PharmD PhD
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, AR
Funding Period: May 2008 - May 2009

BACKGROUND/RATIONALE:
Prevalence of depression (DEP), post-traumatic stress disorders (PTSD), and alcohol use disorders (AUD) is high among OEF/OIF Veterans. A large proportion of these Veterans live in rural areas. Research suggests that Veterans living in rural areas may have worse MH status and lower likelihood of being diagnosed with an MH disorder than Veterans in urban areas. This study builds on our previous HSR&D research to examine screening, diagnosis and treatment of these disorders among rural Veterans.

OBJECTIVE(S):
The objectives of this study of OEF/OIF Veterans enrolled in VISN 16 are to: 1) characterize rural/urban differences in clinical services utilization; 2) identify rural residence differences in detection, diagnosis, and treatment for PTSD, DEP or AUD; and 3) determine potential mediation of these differences by travel distance or service setting.

METHODS:
A retrospective, quasi-experimental design examined screening, diagnosis and treatment for DEP, PTSD and AUD among OEF/OIF Veterans. All study data were obtained from the VISN 16 data warehouse. Inclusionary criteria were: 1) no VA health service use between 7/1/02 and 1/1/08; 2) first clinic visit between 1/1/08 and 3/16/09; 3) at least one VA visit in the 12 months after the first visit; and 4) no screening or diagnosis of PTSD, DEP or AUD prior to the first visit.

FINDINGS/RESULTS:
This sample includes 5411 Veterans, mean age of 31 years. Almost 72% lived in a large metropolitan area (LMA), 14% in a small metropolitan area (SMA), 10% in a small town and 4% in a rural area. Among Veterans screened, 37% were positive for PTSD, 23% for DEP and 24% for AUD. There were no rural/urban differences in PTSD or DEP screening; however, Veterans in SMA had lower odds of AUD screening compared with those in rural areas (p=.05). There were no rural/urban differences for PTSD or AUD diagnosis, but Veterans in LMA or small towns had a higher odds of being diagnosed with DEP, compared with rural areas (p=.001 and p=.0006, respectively). There were no rural/urban differences in receipt of psychotherapy visits or number of visits after PTSD or DEP diagnosis. However, Veterans in small towns were more likely to receive an SSRI and those in LMA were less likely to receive psychotropic medication compared with Veterans in rural areas (p=.04 and p=.01, respectively).

IMPACT:
These analyses suggest no systematic rural/urban differences in screening, diagnosis and treatment of PTSD, DEP or AUD in this cohort. VISN 16 has a strong mental health product line that emphasizes PTSD, DEP and AUD screening, and given that our analyses were confined to this network, these findings indicate that once a Veteran is in the VA health care system, VISN 16 has been able to decrease or eliminate most differences in care based on rural residence, a finding that may vary from national level data. However, importantly, few Veterans from rural areas were included in these analyses, indicating that a very low number of Veterans from rural areas are engaging in care in VISN 16.

PUBLICATIONS:

Journal Articles

  1. Hudson TJ, Fortney JC, Williams JS, Austen MA, Pope SK, Hayes CJ. Effect of rural residence on use of VHA mental health care among OEF/OIF veterans. Psychiatric services (Washington, D.C.). 2014 Dec 1; 65(12):1420-5.
  2. Davis TD, Deen TL, Fortney JC, Sullivan G, Hudson TJ. Utilization of VA mental health and primary care services among Iraq and Afghanistan veterans with depression: the influence of gender and ethnicity status. Military medicine. 2014 May 1; 179(5):515-20.
Conference Presentations

  1. Davis TD, Hudson TJ. Patterns of Service Utilization Among OEF/OIF Women Veterans Suffering from Depression. Poster session presented at: Women's Health Annual Congress; 2011 Apr 1; Washington, DC.
  2. Hudson TJ, Fortney JC, Landes R, Austen M, Williams S. Impact of Rurality on Care for Depression or PTSD among OEF/OIF Veterans. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.


DRA: none
DRE: none
Keywords: none
MeSH Terms: none