Florentina E. Sileanu

Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study

BackgroundLittle is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.ObjectiveTo determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans.Design and ParticipantsWe conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18–44 years who had received primary care in the VA within the prior 12xa0months.Main MeasuresDescriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011–2013 National Survey of Family Growth (NSFG).Key ResultsOverall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended.ConclusionsWhile rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

Overlapping buprenorphine, opioid, and benzodiazepine prescriptions among veterans dually enrolled in Department of Veterans Affairs and Medicare Part D

BACKGROUNDnBuprenorphine is a key tool in the management of opioid use disorder, but there are growing concerns about abuse, diversion, and safety. These concerns are amplified for the Department of Veterans Affairs (VA), whose patients may receive care concurrently from multiple prescribers within and outside VA. To illustrate the extent of this challenge, we examined overlapping prescriptions for buprenorphine, opioids, and benzodiazepines among veterans dually enrolled in VA and Medicare Part D.nnnMETHODSnWe constructed a cohort of all veterans dually enrolled in VA and Part D who filled an opioid prescription in 2012. We identified patients who received tablet or film buprenorphine products from either source. We calculated the proportion of buprenorphine recipients with any overlapping prescription (based on days supply) for a nonbuprenorphine opioid or benzodiazepine, focusing on veterans who received overlapping prescriptions from a different system than their buprenorphine prescription (Part D buprenorphine recipients receiving overlapping opioids or benzodiazepines from VA and vice versa).nnnRESULTSnThere were 1790 dually enrolled veterans with buprenorphine prescriptions, including 760 (43%) from VA and 1091 (61%) from Part D (61 veterans with buprenorphine from both systems were included in each group). Among VA buprenorphine recipients, 199 (26%) received an overlapping opioid prescription and 11 (1%) received an overlapping benzodiazepine prescription from Part D. Among Part D buprenorphine recipients, 208 (19%) received an overlapping opioid prescription and 178 (16%) received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients with cross-system opioid overlap, 25% (49/199) and 35% (72/208), respectively, had >90xa0days of overlap.nnnCONCLUSIONSnMany buprenorphine recipients receive overlapping prescriptions for opioids and benzodiazepines from a different health care system than the one in which their buprenorphine was filled. These findings highlight a previously undocumented safety risk for veterans dually enrolled in VA and Medicare.

Impact of Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits on Potentially Unsafe Opioid Use

Objectives To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D. Methods Among US veterans enrolled in both VA and Part D filling 1 or more opioid prescriptions in 2012 (nu2009=u2009539u2009473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source. Results Overall, 135u2009643 (25.1%) veterans received opioids from VA only, 332u2009630 (61.7%) from Part D only, and 71u2009200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio [ARR]u2009=u20093.0; 95% confidence interval [CI]u2009=u20092.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted differenceu2009=u200916.4 days; 95% CIu2009=u200915.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARRu2009=u20092.2; 95% CIu2009=u20092.1, 2.3). Conclusions Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.

Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study

OBJECTIVEnTo assess whether racial/ethnic disparities in contraceptive knowledge observed in the general US population are also seen among women Veterans served by the Veterans Affairs (VA) healthcare system.nnnSTUDY DESIGNnWe analyzed data from a national telephone survey of 2302 women Veterans aged 18-44 who had received care within VA in the prior 12 months. Twenty survey items assessed womens knowledge about various contraceptive methods. Multivariable logistic regression was used to examine racial/ethnic variation in contraceptive knowledge items, adjusting for age, marital status, education, income, parity, and branch of military service.nnnRESULTSnContraceptive knowledge was low among all participants, but black and Hispanic women had lower knowledge scores than whites in almost all knowledge domains. Compared to white women, black women were significantly less likely to answer correctly 15 of the 20 knowledge items, with the greatest adjusted difference observed in the item assessing knowledge about the reversibility of tubal sterilization (adjusted percentage point difference (PPD): -23.0; 95% CI: -27.8, -18.3). Compared to white women, Hispanic women were significantly less likely to answer correctly 11 of the 20 knowledge items, with the greatest adjusted difference also in the item assessing tubal sterilization reversibility (PPD: -13.1; 95% CI: -19.5, -6.6).nnnCONCLUSIONnContraceptive knowledge among women Veterans served by VA is suboptimal, especially among racial/ethnic minority women. Improving womens knowledge about important aspects of available contraceptive methods may help women better select and effectively use contraception.nnnIMPLICATIONSnProviders in the VA healthcare system should assess and address contraceptive knowledge gaps as part of high-quality, patient-centered reproductive health care.

Physicians’ Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study

BackgroundThe Department of Veterans Affairs (VA) has implemented robust strategies to monitor prescription opioid dispensing, but these strategies have not accounted for opioids prescribed by non-VA providers. State-based prescription drug monitoring programs (PDMPs) are a potential tool to identify VA patients’ receipt of opioids from non-VA prescribers, and recent legislation requires their use within VA.ObjectiveTo evaluate VA physicians’ perspectives and experiences regarding use of PDMPs to monitor Veterans’ receipt of opioids from non-VA prescribers.DesignQualitative study using semi-structured interviews.ParticipantsForty-two VA primary care physicians who prescribed opioids to 15 or more Veterans in 2015. We sampled physicians from two states with PDMPs (Massachusetts and Illinois) and one without prescriber access to a PDMP at the time of the interviews (Pennsylvania).ApproachFrom February to August 2016, we conducted semi-structured telephone interviews that addressed the following topics regarding PDMPs: overall experiences, barriers to optimal use, and facilitators to improve use.Key ResultsVA physicians broadly supported use of PDMPs or desired access to one, while exhibiting varying patterns of PDMP use dictated by state laws and their clinical judgment. Physicians noted administrative burdens and incomplete or unavailable prescribing data as key barriers to PDMP use. To facilitate use, physicians endorsed (1) linking PDMPs with the VA electronic health record, (2) using templated notes to document PDMP use, and (3) delegating routine PDMP queries to ancillary staff.ConclusionsDespite the time and administrative burdens associated with their use, VA physicians in our study broadly supported PDMPs. The application of our findings to ongoing PDMP implementation efforts may strengthen PDMP use both within and outside VA and improve the safe prescribing of opioids.

Induced abortion among women veterans: data from the ECUUN study

OBJECTIVEnWe compared rates of induced abortion among women veterans receiving Veterans Affairs (VA) healthcare to rates in the general US population, as current policy prohibits VA provision of abortion counseling or services even when pregnancy endangers a veterans life.nnnMETHODSnWe analyzed data from 2298 women veterans younger than 45 years who completed a telephone-based, cross-sectional survey of randomly sampled English-speaking women from across the United States who had received VA healthcare. We compared lifetime, last-5-year and last-year rates of unintended pregnancy and abortion among participants to age-matched data from the National Survey of Family Growth. As few abortions were reported in the last year, we used multivariable logistic regression to examine associations between abortion in the last 5 years and age, race/ethnicity, income, education, religion, marital status, parity, geography, deployment history, housing instability, and past medical and mental health among VA patients.nnnRESULTSnWomen veterans were more likely than matched US women to report ever having an abortion [17.7%, 95% confidence interval (CI): 16.1%-19.3% vs. 15.2% of US women]. In the last 5 years, unintended pregnancy and abortion were reported by veterans at rates similar to US women. In multivariable models, VA patients were more likely to report abortion in the last 5 years if their annual income was less than

Associations Between Perceived Race-based Discrimination and Contraceptive Use Among Women Veterans in the ECUUN Study

40,000 (adjusted odds ratio (OR) 2.95, 95% CI 1.30-6.70), they had experienced homelessness or housing instability (adjusted OR 1.91, 95% CI 1.01-3.62), they were single (adj. OR 2.46, 95% CI 1.23-4.91) and/or they had given birth (adjusted OR 2.29, 95% CI 1.19-4.40).nnnCONCLUSIONnWomen veterans face unintended pregnancy and seek abortion as often as the larger US population.nnnIMPLICATIONSnThe Veterans Health Care Act, which prohibits provision of abortion services, increases vulnerable veterans out-of-pocket healthcare costs and limits veterans reproductive freedom.

Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans

Objective: To describe perceived race-based discrimination in Veterans Affairs (VA) health care settings and assess its associations with contraceptive use among a sample of women Veterans. Methodology: This study used data from a national telephone survey of women Veterans aged 18–44 receiving health care in VA who were at risk of unintended pregnancy. Participants were asked about their perceptions of race-based discrimination while seeking VA health care and about their contraceptive use at last heterosexual intercourse. Logistic and multinomial regression analyses were used to examine associations between perceived race-based discrimination with use of prescription contraception. Results: In our sample of 1341 women Veterans, 7.9% report perceived race-based discrimination when receiving VA care, with blacks and Hispanics reporting higher levels of perceived discrimination than white women (11.3% and 11.2% vs. 4.4%; P<0.001). In logistic and multinomial regression analyses adjusting for race/ethnicity, age, income, marital status, parity, and insurance, women who perceived race-based discrimination were less likely to use any prescription birth control than women who did not (odds ratio, 0.65; 95% confidence interval, 0.42–1.00), with the largest difference seen in rates of intrauterine device or implant use (odds ratio, 0.40; 95% confidence interval, 0.20–0.79). Conclusions: In this national sample of women Veterans, over 10% of racial/ethnic minority women perceived race-based discrimination when receiving care in VA settings, and perceived racial/ethnic discrimination was associated with lower likelihood of prescription contraception use, especially intrauterine devices and implants. VA efforts to enhance respectful interactions may not only improve patient health care experiences, but also represent an opportunity to improve reproductive health outcomes for women Veterans.

Medical contraindications to estrogen and contraceptive use among women veterans

BACKGROUNDnFew studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans.nnnOBJECTIVESnTo describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans.nnnMETHODSnIn a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only.nnnRESULTSnAmong 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death.nnnCONCLUSIONSnMany VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.

Male Partner Reproductive Coercion among Women Veterans

Background Women veterans have high rates of medical comorbidities and may be particularly vulnerable to adverse health outcomes associated with unintended pregnancy. Objectives The objective of the study was to estimate the prevalence of medical contraindications to estrogen‐containing combined hormonal contraception among women veterans of reproductive age and to evaluate the relationship between contraindications and contraceptive use. Study Design This was a secondary analysis of data from a cross‐sectional, telephone‐based survey with a national sample of 2302 female veterans, aged 18–45 years, who use the Veterans Administration Healthcare System for primary care. This analysis included women at risk of unintended pregnancy, defined as heterosexually active and not pregnant or trying to conceive and with no history of hysterectomy or infertility. Seven contraindications to combined hormonal contraception were identified using survey data or medical diagnosis codes: hypertension; coronary artery disease; active migraine in women older than 35 years or migraine with aura; smoking in women older than 35 years; and a history of thromboembolism, stroke, or breast cancer. Outcomes were current use of combined hormonal contraception and contraceptive method type (combined hormonal contraception, and other prescription methods, nonprescription methods or no method). Multivariable logistic and multinomial regression were used to assess the relationship between contraindications and combined hormonal contraception use and method type, respectively. Results Among 1169 women veterans at risk of unintended pregnancy, 339 (29%) had at least 1 contraindication to combined hormonal contraception. The most prevalent conditions were hypertension (14.9%) and migraine (8.7%). In adjusted analyses, women with contraindications were less likely than women without contraindications to report use of combined hormonal contraception (adjusted odds ratio, 0.54, 95% confidence interval, 0.37–0.79). Relative to use of combined hormonal contraception, women with contraindications were more likely than women without contraindications to use other prescription methods (adjusted odds ratio, 1.74, 95% confidence interval, 1.17–2.60), nonprescription methods (adjusted odds ratio, 1.96, 95% confidence interval, 1.19–3.22), and no method (adjusted odds ratio, 2.29, 95% confidence interval, 1.35–3.89). Conclusion Women veterans at risk of unintended pregnancy have a high burden of medical contraindications to estrogen. Women with contraindications were less likely to use combined hormonal contraceptive methods but were more likely to use no method, suggesting an unmet need for contraception in this medically vulnerable population.