Post-traumatic stress disorder (PTSD) is thought to affect nearly one-fifth of Veterans of Operations Enduring Freedom (OEF; Afghanistan), Iraqi Freedom (OIF; Iraq), and New Dawn (OND; Iraq). Recognizing that evidence-based practices (EBPs) for PTSD can result in significant symptom reduction and improved quality of life for Veterans with the disorder, the Department of Veterans Affairs (VA) has invested in making EBPs for PTSD available at every VA facility nationwide; however, many recent Veterans elect to seek care in community settings rather than with VA. Seeking to inform VA efforts to improve access to high-quality, patient-centered care, we compared PTSD care utilization patterns among OEF/OIF/OND Veterans with PTSD living in Texas. As Texas has the nation's second largest population of Veterans, with widely varying demographics and access to VA and other services, it provides an excellent case study for examining care seeking, access to care, and care preferences among recent Veterans.
Aim 1. Compare demographic characteristics of OEF/OIF/OND Veterans with PTSD in Texas who report different patterns of PTSD care utilization over the past 12 months (VA only/Non-VA only/Dual care/No professional care).
Aim 2. Compare PTSD care preferences, perceived access and perceived need for care among individuals with different patterns of PTSD care utilization.
Aim 3. Identify geographic factors such as proximity and density of PTSD care services associated with different patterns of PTSD care utilization.
We used a crosswalk of VA administrative data from the OEF/OIF/OND Roster and VETSNET to identify all OEF/OIF/OND Veterans living in Texas with service-connected disability for PTSD (approximately 27,500 persons). Veterans in the study cohort were stratified into eight groups based on sex, rurality, and use of any VA care during fiscal years 2012 and 2013, with the intent to oversample females, rural residents, and non-users of routine VA medical services. Members from each strata (n=1124) were randomly selected and mailed invitations to participate in an online or paper survey using a modified Dillman method. We received 256 responses, which, after accounting for bad addresses, provided an overall response rate of 26.9%. Survey data assessed utilization of VA, military, and community-based care services, care preferences, and patient-level factors as described in the model of Veterans' healthcare access developed by the State of the Art (SOTA) Conference on Improving Access to VA Care (Fortney et al, 2011). Respondents were classified into four care utilization groups based upon reported settings in which they received PTSD care in the prior 12 months: VA care only, non-VA care only, Dual care, and No professional care.
Initial statistical analysis included: 1) comparison of the proportion of respondents within various demographic categories across the four care utilization groups; 2) comparison of attitudes about barriers to receiving care across utilization groups; and 3) regression analyses to determine which reported characteristics and attitudes were most influential in predicting the care utilization group of each veteran. We accounted for intentional oversampling and difference in response rates between stratification groups by weighting survey responses, then used chi-square and Pearson correlation coefficients to measure associations between variables and assess collinearity before conducting multinomial logistic regression.
In the prior 12 months, an estimated 57% of OEF/OIF/OND Veterans with service connection for PTSD living in Texas received PTSD-related care at VA facilities only, 9% received PTSD care in non-VA settings (either military or community-based), and 14% received care in both VA and non-VA settings. The remaining 20% reported no professional PTSD care in the prior year. Utilization groups showed statistically significant differences in the following characteristics: income, employment status, total duration of time deployed, eligibility for Department of Defense (DoD) healthcare, whether the respondent had ever received PTSD care at a VA or community-based facility, and attitudes about medication and overall willingness to seek mental health care.
Results of the model analyses indicate that the most important factors for predicting utilization group include race, education level, income, total length of time deployed, DoD eligibility, current use of VA for non-PTSD-related care, and prior experience of PTSD care at a VA or community-based facility. Factors that had little to no predictive value included sex, rurality, expressed preferences for care in the VA or military setting, health self-assessment, and prior experience of PTSD care in a military facility. Attitudes associated with current care-seeking pattern included not wanting to receive medication, overall reluctance to seek mental health care, and understanding information about PTSD from health care providers. Attitude statements regarding concerns about stigma among family or in the workplace were of little to no predictive value.
Findings of this pilot study suggest that - in accordance with the SOTA model - a variety of factors impact care seeking for OEF/OIF/OND Veterans with PTSD in Texas, including current and past experiences of care in VA and non-VA settings. Approximately 23% of respondents reported receiving non-VA care in the prior 12 months, either with or without accompanying VA care, suggesting VA may face challenges in ensuring coordination and quality of PTSD care across settings. Another 20% of respondents reported no professional PTSD care in the prior 12 months, which may indicate a need for increased efforts to support appropriate treatment engagement over time.
Although findings will require replication in a national sample, these results suggest that models predicting PTSD care utilization across VA and non-VA settings need to account for specific Veteran characteristics and overall patterns of care utilization, including use of VA for routine non-PTSD-related care. Efforts to improve attitudes toward care-seeking and increase the perceived patient-centeredness of care are likely to play an important role in encouraging Veterans with PTSD to engage in appropriate care seeking over time.
None at this time.
Mental, Cognitive and Behavioral Disorders