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United States Veterans have a higher prevalence of overweight and related chronic conditions compared to the general population. Although diet is a primary and modifiable contributor to these conditions, little is known about factors influencing diet quality among Veterans. The goal of this study is to examine individual, social environment, and physical environment correlates of general diet quality among Veterans. Study participants (N=653) received care at an urban VA Medical Center in Seattle, WA and completed a mailed survey in 2012 and 2013. Diet quality was assessed with Starting the Conversation, an instrument that measures consumption of unhealthy snacks, fast food, desserts, sugar-sweetened beverages, and fats; fruits and vegetables; and healthy proteins. Variables significantly (p<0.05) associated with diet quality in bivariate analyses were included in a multivariate regression. In the multivariate model, higher level of depressive symptom severity (Diff=0.05; CI=0.01, 0.09; p=0.017); not having others eat healthy meals with the Veteran (Diff=-0.81; CI=-1.5, -0.1; p=0.022); and reduced availability of low-fat foods in neighborhood stores where the Veteran shops (Diff=-0.37; CI=-0.6, -0.2; p<0.001) were associated with poorer diet quality. Consistent with prior research in the general population, this study identified multiple domains associated with Veterans' diet quality, including psychological comorbidity, the social environment, and the physical environment. Findings from this study suggest that interventions aimed at mental health, social support, and neighborhood access to healthy foods are needed to improve Veteran diet quality., (Published by Elsevier Ltd.)

Purpose of the Study: To compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes., Design and Methods: Among women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans., Results: Both non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function., Implications: Chronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function., (Published by Oxford University Press on behalf of the Gerontological Society of America 2016.)

Rationale: Veterans, especially those using U.S. Department of Veterans Affairs (VA) healthcare, have poorer health than the general population. In addition, Veterans using VA services are more likely than non-VA users to be physically inactive. Little is known about physical activity correlates among Veterans. To identify targets for health promotion interventions, understanding barriers to and facilitators of physical activity in this population is critical., Methods: This study examined individual-, social-, and perceived neighborhood-level associations of meeting weekly physical activity recommendations (150 min/week of combined leisure and transportation activity) based on the International Physical Activity Questionnaire (IPAQ) among N = 717 patients from VA Puget Sound, Seattle Division using a mailed survey sent 2012-2013 (response rate = 40%). Independent associations were identified with direct estimation of relative risks using generalized linear models (dichotomous outcome), and linear regression (continuous outcome), including variables associated in bivariate tests (p < .05)., Results: Most participants were male, Caucasian, and unemployed, and had an annual income ≤$40,000. Over two-thirds (69.9%) reported meeting physical activity recommendations. Fewer days of limitations due to physical or mental health (Relative Risk (RR) = 0.99 per day; 95% Confidence Interval (CI) = 0.98, 0.99; p = .01), others doing physical activity with the Veteran (RR = 1.18; 95% CI = 1.04, 1.33; p = .01), receiving ideas from others regarding physical activity (RR = 1.14; 95% CI = 1.01, 1.29; p = .03) and better perceived neighborhood aesthetics (RR = 1.14; 95% CI = 1.06, 1.24; p = .001) were associated with meeting physical activity recommendations. Findings were comparable for total weekly physical activity, but lower depression symptom severity was also associated with increased physical activity., Conclusion: This study identified individual and contextual correlates of physical activity among VA-using Veterans. Targeting these factors will be important in promoting physical activity in order to address the disproportionate disease burden facing U.S. Veterans. Existing VA interventions targeting physical activity may need to be adapted to account for the influence of contextual factors., (Published by Elsevier Ltd.)

Background: Women veterans using Veterans Administration (VA) health care have high rates of medical and mental health comorbidities, placing them at increased risk of poor outcomes from unplanned pregnancy. Reproductive life planning is a strategy recommended by the U.S. Centers of Disease Control and Prevention that could promote healthy pregnancies and reduce unplanned pregnancy in the VA. However, no data exist on women veterans' perceptions of reproductive life planning discussions., Methods: We trained six VA primary care physicians at two VA Women's Health Clinics to conduct reproductive life planning discussions with veterans aged 18 to 44 during primary care visits. After the visit, we performed semistructured telephone interviews with consenting veterans to explore perceptions of 1) reproductive life planning content and 2) provider-patient communication in reproductive life planning discussions. Interviews were audiorecorded, transcribed, and analyzed using content analysis., Results: We interviewed 27 veterans with a mean age of 31 years (range, 22-42). Women veterans perceived generally reproductive life planning discussions as important opportunities to discuss reproductive goals with providers and to obtain new and relevant information about contraception, planning healthy pregnancies, and available VA reproductive health services. Perceptions of reproductive life planning content were influenced by women's pregnancy intentions. Perceptions related to provider-patient communication included preferences for provider-initiated discussions and nonjudgmental counseling that incorporates patients' values and preferences., Conclusions: Women veterans perceived reproductive life planning as valuable and important to their health. Reproductive life planning has the potential to enhance patient-centered delivery of reproductive health services in VA primary care., (Published by Elsevier Inc.)

Purpose: Veterans in rural areas generally have lower health care utilization than veterans in urban areas, but the impact of this difference on health outcomes has received little study. Chronic wounds provide a model for studying access to complex chronic care since they often are related to underlying health conditions and require lengthy treatment. Our goals were to describe chronic wound care utilization among rural and urban veterans and to determine the association between rural residence and wound healing., Methods: We conducted a retrospective cohort study of 160 rural and 160 urban veterans in the Pacific Northwest with an incident of chronic lower limb wound between October 1, 2006, and September 30, 2007. We followed individuals for up to 1 year, measuring wound care utilization within Veterans Health Administration and Medicare. We compared wound healing using a competing risks proportional hazards model accounting for amputation and death., Findings: Rural veterans had fewer outpatient wound care visits (6.8 vs 9.9) than urban veterans and a similar number of inpatient wound care stays (0.9 and 0.8, respectively). During follow-up, 234 veterans' wounds healed (77% rural, 69% urban). The adjusted hazard ratio for wound healing was 1.11 (95% confidence intervals [CI]: 0.84-1.47, P = .45) for rural compared to urban veterans. The hazard of amputation was higher among rural veterans (hazard ratio [HR] = 2.65, 95% CI: 1.02-6.87, P = .045) and the hazard of death was lower (HR = 0.35, 95% CI: 0.12-0.97, P = .043)., Conclusions: Despite lower wound care utilization, rural veterans' wounds were as likely to heal as urban veterans' wounds., (© 2015 National Rural Health Association.)

Evidence-based ulcer care guidelines detail optimal components of care for treatment of ulcers of different etiologies. We investigated the impact of providing specific evidence-based ulcer treatment components on healing outcomes for lower limb ulcers (LLU) among veterans in the Pacific Northwest. Components of evidence-based ulcer care for venous, arterial, diabetic foot ulcers/neuropathic ulcers were abstracted from medical records. The outcome was ulcer healing. Our analysis assessed the relationship between evidence-based ulcer care by etiology, components of care provided, and healing, while accounting for veteran characteristics. A minority of veterans in all three ulcer-etiology groups received the recommended components of evidence-based care in at least 80% of visits. The likelihood of healing improved when assessment for edema and infection were performed on at least 80% of visits (hazard ratio [HR] = 3.20, p = 0.009 and HR = 3.54, p = 0.006, respectively) in patients with venous ulcers. There was no significant association between frequency of care components provided and healing among patients with arterial ulcers. Among patients with diabetic/neuropathic ulcers, the chance of healing increased 2.5-fold when debridement was performed at 80% of visits (p = 0.03), and doubled when ischemia was assessed at the first visit (p = 0.045). Veterans in the Pacific Northwest did not uniformly receive evidence-based ulcer care. Not all evidence-based ulcer care components were significantly associated with healing. At a minimum, clinicians need to address components of ulcer care associated with improved ulcer healing., (© 2015 by the Wound Healing Society.)

Objective: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits., Study Design: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using χ2 tests with Rao-Scott adjustment. All analyses used sampling weights., Results: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p=.03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p=.02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p=.02]; PTSD, 52.5% vs. 14.8% [p=.02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p<.001)., Conclusion: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care., (Published by Elsevier Inc.)

Background: Multiple limb loss from combat injuries has increased as a proportion of all combat-wounded amputees. Bilateral lower-extremity limb loss is the most common, with bilateral transfemoral amputations being the most common subgroup followed by bilateral amputations consisting of a single transfemoral amputation and a single transtibial amputation (TFTT). With improvements in rehabilitation and prostheses, we believe it is important to ascertain how TFTT amputees from the present conflicts compare to those from the Vietnam War., Questions/purposes: We compared self-reported (1) health status, (2) quality of life (QoL), (3) prosthetic use, and (4) function level between TFTT amputees from the Vietnam War and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)., Methods: As part of a larger survey, during 2007 to 2008, servicemembers with a diagnosis of amputation associated with battlefield injuries from the Vietnam War and OIF/OEF were identified from the Veterans Affairs and military databases. Participants were asked to respond to a questionnaire to determine their injuries, surgical history, presence of other medical problems, health status, QoL, function, and prosthetic use. We assessed QoL and health status using single-item questions and function using seven categories of physical activity. Thirteen of 298 (4.3%) participants in the Vietnam War group and 11 of 283 (3.8%) in the OIF/OEF group had sustained TFTT amputations. Mean age ± SD at followup was 61 ± 2 years and 28 ± 5 years for the Vietnam War and OIF/OEF groups, respectively., Results: Excellent, very good, and good self-reported health (85% versus 82%; p = 0.85) and QoL (69% versus 72%; p = 0.85) were similar between the Vietnam War and OIF/OEF groups, respectively. Level of function was higher in the OIF/OEF group, with four of 11 reporting participation in high-impact activities compared to none in the Vietnam War group (p = 0.018)., Conclusions: Participants with TFTT limb loss from both conflicts reported similar scores for QoL and health status, although those from OIF/OEF reported better function and use of prosthetic devices. It is unclear whether the improved function is from age-related changes or improvements in rehabilitation and prosthetics. Some areas of future research might include longitudinal studies of those with limb loss and assessments of physical function of older individuals with limb loss as the demographics shift to where this group of individuals becomes more prominent.

Background: Women veterans are a growing population with unique characteristics and documented health disparities. Few studies have examined their sexual behaviors and rates of sexually transmitted infections (STIs), and none have compared women veterans to nonveterans to identify potential sexual health disparities., Methods: We used data from the 1999-2010 National Health and Nutrition Examination Survey, a nationally representative U.S. survey. We compared lifetime sexual history (age at first intercourse, number of partners), sexual activity in the last year, and STIs between women veterans (n=151) and nonveterans (n=8738), adjusting for age, race/ethnicity, education, marital status, binge drinking, and survey year., Results: Compared to nonveterans, women veterans reported a younger age at first intercourse and a greater number of female and male lifetime sexual partners, and they were more likely to have ever had sex with a woman. They were also more likely than nonveterans to have genital herpes and genital warts., Conclusions: Women veterans reported higher rates of sexual activity and STIs than nonveterans. Future research is needed to assess high-risk behaviors and determine what factors may underlie these associations. Providers should ensure thorough screening and intervention services are provided for this growing population.

Purpose: The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention., Methods: From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding., Results: The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001)., Conclusions: An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.

The number of women veterans is rapidly growing, and little is known regarding the health and healthcare needs of women veterans with traumatic limb loss. The objective of this study was to summarize physical and mental health conditions and rates of prosthetic prescriptions among women service members and veterans with major traumatic limb loss. Researchers and clinicians who administered the Survey for Prosthetic Use contacted and enrolled 283 servicemembers and veterans of Operation Iraqi Freedom/Operation Enduring Freedom with major traumatic limb loss. Participants provided information on health status; comorbidities; other combat injuries; and prosthetic device use, rejection, and replacement. Of the 283 veterans, 9 (3%) were women. Compared with men, women reported more than a threefold higher prevalence of migraine (67% vs 20%, p = 0.001). Compared with men, women received 0.42 more prostheses per year, rejected 0.11 more prostheses per year, but replaced 0.18 fewer prostheses per year. With the exception of migraine headaches, men and women servicemembers and veterans with major traumatic limb loss report similarly high prevalence of physical and mental health conditions. Women report higher rates of prosthesis receipt and rejection and lower rates of prosthesis replacement than men. These findings highlight some potential issues specific to women veterans that may require additional clinical attention.

Problem: Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes., Methods: This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity and comorbid medical and mental health conditions., Results: Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minor amputations. Diagnosed depression was associated with an adjusted HR of 1.33 (95% CI: 1.15-1.55) for major amputations. There was no statistically significant association between depression and minor amputations (adjusted HR 1.01, 95% CI: 0.90-1.13)., Conclusions: Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans., Methods: The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured., Results: Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year., Conclusions: Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.

Objectives: To compare influenza and pneumococcal vaccination rates of older veterans with those of nonveterans and to compare vaccination rates of veterans who receive care at U.S. Department of Veterans Affairs (VA) medical centers with those of veterans who do not., Design: Cross-sectional population-based study., Setting: United States and territories., Participants: Persons aged 65 and older who participated in the 2003 Behavioral Risk Factor Surveillance System., Measurements: Telephone survey of sociodemographics factors, including veteran status and VA care, health and behavioral characteristics, and influenza and pneumococcal vaccine use., Results: Thirty percent of adults aged 65 and older were veterans, and 21% of veterans reported receiving care at VA health facilities. Veterans, especially VA users, were older and described poorer self-perceived health than nonveterans. Influenza and pneumococcal vaccination rates were higher for veterans than for nonveterans (74% vs 68% and 68% vs 63%, respectively, P < .001 for both) and for VA users than non-VA users (80% vs 72% and 81% vs 64%, respectively, P < .001 for both). For veterans, VA care was independently associated with influenza (odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.5-2.2) and pneumococcal (OR = 2.4, 95% CI = 2.0-2.9) vaccine use after adjusting for sociodemographics factors, perceived health status, diabetes mellitus, asthma, and smoking. Current smoking and black race were independent predictors of low influenza vaccine uptake., Conclusion: VA care was associated with improved influenza and pneumococcal vaccine coverage, although vaccination rates for all elderly veterans fell short of Healthy People 2010 goals. Increased efforts to reach undervaccinated groups, particularly blacks and smokers, are warranted.

Objective: To determine whether amputees have an increased risk of knee pain or symptomatic osteoarthritis (OA) compared with nonamputees., Design: Retrospective cohort study., Setting: Veterans Administration Patient Treatment and Outpatient Care files., Participants: All male unilateral (transtibial or transfemoral) traumatic amputee patients and a random sample of male nonamputees. Patients were excluded if they were younger than 40 years, had sustained a significant injury to their knee(s), or had a rheumatic disease., Interventions: Not applicable., Main Outcome Measures: The prevalence of knee pain and symptomatic knee OA., Results: The age and average weight-adjusted prevalence ratio of knee pain among transtibial amputees, compared with nonamputees, was 1.3 (95% confidence interval [CI], 0.7-2.1) for the knee of the intact limb and 0.2 (95% CI, .05-0.7) for the knee of the amputated limb. The standardized prevalence ratio of knee pain in the intact limb and symptomatic OA among transfemoral amputees, compared with nonamputees, was 3.3 (95% CI, 1.5-6.3) and 1.3 (95% CI, 0.2-4.8), respectively., Conclusions: Stresses on the contralateral knee of amputees may contribute to secondary disability. Possible explanations include gait abnormalities, increased physiologic loads on the knee of the intact limb, and the hopping and stumbling behavior common in many younger amputees.

Objective: To compare behavioral risk factors and health and disease characteristics among three groups of adults with diabetes: nonveterans, veterans not receiving Department of Veterans Affairs (VA) health care, and veterans using VA services., Research Design and Methods: Two data sources were used to describe the veteran population. First, the 2000 Behavioral Risk Factor Surveillance System (BRFSS) characterized the U.S. adult population by preventive health practices and risk behaviors linked to chronic and preventable diseases. New to the 2000 survey were questions on veteran status, which were administered in all states. Second, VA administrative and veterans benefits data were analyzed to describe comorbidity, education services, and veterans benefits., Results: The estimated prevalence of diabetes in male veterans receiving VA care was 16%. Male veterans with diabetes using VA care were more likely to be nonwhite, not employed, have lower income, lower health status, and more activity limitations than male veterans not using these services. Computerized records indicate VA users with diabetes also had high concurrent comorbidity. Frequency of VA diabetes and preventive care services, as measured by selected quality indicators, was equivalent to or higher than the levels reported by veterans not receiving VA care and nonveterans. In addition to health care, nearly one-fourth of veterans with diabetes also received monthly awards for compensation and pension., Conclusions: Males receiving VA care with self-reported diabetes indicated receiving preventive care services at equivalent or higher levels than their counterparts receiving care outside the VA and nonveterans.

Objective: To describe the epidemiology of lower-extremity complications of diabetes in veterans who are users of the Department of Veterans Affairs (VA)., Research Design and Methods: Hospital discharge records for care provided in all VA hospitals in 1998 were obtained. All hospitalizations for lower-extremity ulceration, peripheral vascular procedures, and amputation were analyzed using frequency tables. A diabetes denominator was defined as a veteran with at least three ambulatory care visits with at least one diabetes diagnosis code. Age-specific and total age-adjusted rates of discharge with ulceration, vascular procedures, and amputation were calculated., Results: Veterans with diabetes comprised over half of all hospitalizations for lower-extremity ulceration, one-third of all hospitalizations for peripheral vascular procedures, and two-thirds of all hospitalizations for amputation. The age-specific discharge rate per 1,000 diabetic persons for age 0-64 years, 65-74 years, and 75 years and older for ulceration were 28.4, 31.0, and 37.9; for vascular procedures, the rates were 3.5, 4.4, and 4.4; and for amputation, the rates were 7.3, 9.0, and 10.0, respectively., Conclusions: Veterans with diabetes comprise a significant proportion of hospitalizations for lower-extremity ulceration, peripheral vascular bypass, and amputation. Age-specific rates of diabetic amputation in veterans are lower than U.S. rates.

Purpose of the studyTo compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes.Design and methodsAmong women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans.ResultsBoth non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function.ImplicationsChronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function.

Background Veterans who use the Veterans Health Administration (VHA) also may use Medicare coverage for treatment outside VHA. Using multiple health care systems introduces fragmentation and may increase utilization. The purpose of this study was to compare chronic wound care utilization among VHA-Medicare dual system users and VHA-exclusive users. Methods Using data from VHA chart review and Medicare claims, we conducted a retrospective cohort study of 203 Medicare-enrolled VHA users with an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 and followed them for up to one year. We identified all VHA and Medicare wound-care visits during the wound episode. Results 19.7% of the cohort was dual users. Dual users had higher observed wound care utilization than VHA-exclusive users (11.9 versus 7.6 outpatient visits [p = 0.002] and 1.6 versus 0.7 inpatient stays [p = 0.0008]). After adjusting for covariates including wound duration, dual users were predicted to have 8.6 outpatient wound care visits and 1.1 inpatient wound care stays while VHA-exclusive users were predicted to have 7.0 (p = 0.07) outpatient visits and 0.7 (p = 0.05) inpatient stays. Conclusions Dual use contributes to higher wound care utilization potentially because of longer wound duration. [ABSTRACT FROM AUTHOR]

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care. [ABSTRACT FROM AUTHOR]

Engaging in regular physical activity (PA), with or without a corresponding decrease in weight, is associated with improved health outcomes. The purpose of this study was to quantify the extent to which PA differed between veterans and nonveterans and to determine how diabetes and age influenced this association. Data from the 2009 Behavioral Risk Factor Surveillance System were used in this study. Respondents were classified as having diabetes if they reported ever being diagnosed with diabetes except during pregnancy. Respondents who reported ever serving on active military duty were classified as veterans. Based on self-report, we calculated the average minutes per week of moderate, vigorous, and total activity. After adjusting for sex, race and ethnicity, household income, education level, body mass index (BMI), and recent health checkup, veteran status was associated with a small but significantly larger amount of average weekly moderate PA (2.2 minutes, P = 0.0058) but not average weekly vigorous PA (-0.02 minutes, P = 0.98). Diabetes and prediabetes were associated with significantly lower mean levels of both moderate and vigorous intensity PA, as was increasing age. Consistent with prior research, veterans engaged in more PA than nonveterans. The association between diabetes, age, and physical activity did not differ by veteran status. [ABSTRACT FROM AUTHOR]

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention. [ABSTRACT FROM AUTHOR]

The authors discuss the result of the Survey for Prosthetic Use launched by the Health Services Research and Development (HSR&D) of the U.S. Department of Veterans Affairs (VA). The survey covers Vietnam Veterans and service members from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who suffered major traumatic limb loss. The methodolody used in the survey is described.

The article presents a response from the authors of a report in a 2014 issue, titled "Antidepressant Adherence and Risk of Coronary Artery Disease Hospitalizations in Older and Younger Adults With Depression," to a letter to the editor regarding their study.

Many resources are available for servicemembers who experience combat-associated major limb loss. Navigating print, Internet, and in-person information and services is key. This appendix identifies sources of information for individuals with major limb loss as follows: (1) resources for military per­sonnel, (2) resources from the Department of Veterans Affairs, (3) other resources for veterans, (4) resources for family mem­bers, and (5) resources in the public domain. Five detailed tables identify some of the agencies, their contact information, and some of the services available in each of these five categories. [ABSTRACT FROM AUTHOR]

Veterans injured in theaters of combat operations are eligible for benefits, including medical care and compensation. This article describes veterans with service-connected disability for major lower- and/or upper-limb loss resulting from combat-field-associated injuries sustained in the Vietnam war, Operation Desert Shield/Operation Desert Storm, and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Using the Department of Veterans Affairs (VA) Compensation and Pension Mini-Master file, we identified 2,690 veterans who in August 2007 received compensation for loss of one or more limbs. More than 97% sustained their injuries in Vietnam; most were young men who served in the U.S. Army or Marine Corps. All but 5% had at least 50% combined service-connected disability and nearly half had a 100% rating. In addition to limb loss, one of the most prevalent compensable conditions was posttraumatic stress disorder, present in 46% of OIF/OEF and 20% of Vietnam veterans. Of these veterans, 82% visited VA outpatient clinics in 2007, although only 4% were hospitalized. A special obligation exists to those who have sustained serious injuries related to combat; this responsibility extends for the life of the servicemember and beyond to his or her spouse and dependents. [ABSTRACT FROM AUTHOR]

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts. [ABSTRACT FROM AUTHOR]

Returning wounded veterans and servicemembers to their highest level of function following traumatic injury is a priority of the Departments of Defense and Veterans Affairs. We surveyed 245 veterans from the Vietnam war and 226 servicemembers and veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts with at least one major traumatic lower-limb loss to determine their use of mobility assistive technology (AT) and patterns of limb abandonment. Prosthetic device use without wheelchair use is found in 50.5% of Vietnam and 42.8% of OIF/OEF groups. Prostheses and supplementary wheelchairs are used by Vietnam (32%) and OIF/OEF (53%) groups (p < 0.01). Exclusive wheelchair use is more frequent in the Vietnam group (18%) than in the OIF/OEF group (4.0%, p < 0.01). In Vietnam participants, multivariate analysis found that multiple-limb loss (adjusted odds ratio [AOR] = 14.5; 95% confidence interval [CI] 5.5-38.5), bilateral lower-limb loss (AOR = 12.7; 95% CI 6.2-26.1), and number of comorbidities (AOR = 1.3; 95% CI 1.2-1.5) are associated with increased likelihood of wheelchair use. In OIF/OEF participants, bilateral lower-limb loss (AOR = 29.8; 95% CI 11.0-80.7), multiple-limb loss (AOR = 16.3; 95% CI 3.1-85.3), cumulative trauma disorder (AOR = 2.4; 95% CI 1.2-4.9), and number of combat injuries (AOR = 1.4; 95% CI 1.2-1.7) are associated with wheelchair use. Combined use of different types of mobility ATs promotes improved rehabilitation and ability to function. [ABSTRACT FROM AUTHOR]

Prosthetic care is a vital aspect of healthcare and rehabilitation for veterans and servicemembers with major traumatic limb loss. Our survey queried 581 veterans and servicemembers with limb loss from the Vietnam and Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) conflicts. Among survey participants, 78.2% from the Vietnam conflict and 90.5% from the OIF/OEF conflict currently use prosthetic devices. In Vietnam respondents, 78% received prosthetic care from private sources, 16% from Department of Veterans Affairs (VA) prosthetic laboratories, 0.9% from Department of Defense (DOD), and 5% from multiple sources. In OIF/OEF respondents, 42% received prosthetic care from private sources, 9% percent from VA, 39% from DOD, and 10% from multiple sources. Participants identified their satisfaction with current prosthetic devices and prosthetic services. Reports of pain, sweating, skin irritation, and problems with socket fit continue to be significant issues for participants from both conflicts regardless of level of amputation or site of service. In those with upper-limb loss who used myoelectric prostheses, minimal effect on prosthesis use and satisfaction was noted. Among lower-limb loss participants from both conflicts, notable differences existed in prosthesis satisfaction by source of care. [ABSTRACT FROM AUTHOR]

Rehabilitation goals following major combat-associated limb loss in World War II and the Vietnam war focused on treatment of the injury and a return to civilian life. The goal for Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) servicemembers is to restore function to the greatest possible degree and, if they desire, return them to Active Duty, by providing them with extensive rehabilitation services and a variety of prosthetic devices. Our study determines the usefulness of these diverse types of prosthetic devices for restoring functional capability and documents prosthesis use and satisfaction. We compare servicemembers and veterans with major combat-associated unilateral lower-limb loss: 178 from the Vietnam war and 172 from OIF/OEF conflicts. Of survey participants with unilateral lower-limb loss, 84% of the Vietnam group and 94% of the OIF/OEF group currently use at least one prosthetic device. Reasons for rejection varied by type of device, but common reasons were pain, prosthesis too heavy, and poor fit. Abandonment is infrequent (11% Vietnam group, 4% OIF/OEF group). Future efforts should aim to improve prosthetic-device design, decrease pain, and improve quality of life for these veterans and servicemembers. [ABSTRACT FROM AUTHOR]

Multiple-limb loss due to war-theater injuries results in a unique group of servicemembers requiring intensive rehabilitation and diverse prosthetic devices. This article compares the Vietnam and the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) groups with war-theater-associated multiple-limb loss to document significant changes in health status, prosthetic-device use, and long-term prognosis. During 2007 and 2008, a national survey queried 73 Vietnam veterans and 61 OIF/OEF servicemembers sustaining multiple-limb loss. Average years since limb loss are 39 for Vietnam veterans and 3 for OIF/OEF servicemembers. Self-rated health status was excellent or very good in 38.9% of the Vietnam group and 60.7% of the OIF/OEF group (p = 0.01). More of the OIF/OEF group than the Vietnam group reported performing high-impact aerobic activities, 18% versus 3% (p = 0.005). The OIF/OEF group currently uses more diverse prosthetic- device types than the Vietnam group. Based on Vietnam veterans' 39-year experience, the long-term prognosis for OIF/OEF servicemembers with multiple-limb loss is an active, fulfilling life. The healthcare team caring for these patients should carefully address proper prosthesis fit and maintenance of good health and function. [ABSTRACT FROM AUTHOR]

Many resources are available for servicemembers who experience combat-associated major limb loss. Navigating print, Internet, and in-person information and services is key. This appendix identifies sources of information for individuals with major limb loss as follows: (1) resources for military personnel, (2) resources from the Department of Veterans Affairs, (3) other resources for veterans, (4) resources for family members, and (5) resources in the public domain. Five detailed tables identify some of the agencies, their contact information, and some of the services available in each of these five categories. [ABSTRACT FROM AUTHOR]