Susan M. Frayne

The Veterans Health Administration and Military Sexual Trauma

OBJECTIVESnWe examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence.nnnMETHODSnWe analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003.nnnRESULTSnScreening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged.nnnCONCLUSIONSnThe VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Womens health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics

Objective:To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence.Design:Survey using a self-administered, anonymous questionnaire.Setting:Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center.Participants:We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire.Measurements and main results:28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status.Conclusions:The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.

The Prevalence of Military Sexual Assault Among Female Veterans' Administration Outpatients

Considerable publicity has focused on sexual violence among military women. The authors report the prevalence of military sexual violence and make comparisons among women veterans who report they experienced sexual violence while in the military and those who did not. Data are from the Veterans Administration (VA) Womens Health Project, which was designed to assess the health status of women veterans receiving VA ambulatory care. The nationally representative sample (N = 3,632) consists of female veterans who had at least one ambulatory visit at a VA facility between July 1, 1994, and June 30, 1995. More than half (55%) of the women report they were sexually harassed while in the military, and almost one quarter (23%) report they were sexually assaulted. There are differences in sociodemographic characteristics, military experiences, and current health perceptions of women who reported sexual harassment or sexual assault while in the military as compared to those who did not. The prevalence of military sexual harassment and sexual assault is high and screening for sexual assault is important in all women patients given the differences between groups.

Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: findings from the TREAT-AF study.

BACKGROUNDnDespite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in atrial fibrillation/flutter (AF).nnnOBJECTIVESnThe goal of this study was to evaluate the association of digoxin with mortality in AF.nnnMETHODSnUsing complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual confounding was assessed by sensitivity analysis.nnnRESULTSnOf 122,465 patients with 353,168 person-years of follow-up (age 72.1 ± 10.3 years, 98.4% male), 28,679 (23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated patients (95 vs. 67 per 1,000 person-years; pxa0< 0.001). Digoxin use was independently associated with mortality after multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, pxa0< 0.001) and propensity matching (HR: 1.21, 95% CI: 1.17 to 1.25, pxa0< 0.001), even after adjustment for drug adherence. The risk of death was not modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin.nnnCONCLUSIONSnDigoxin was associated with increased risk of death in patients with newly diagnosed AF, independent of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge current cardiovascular society recommendations on use of digoxin in AF.

Medical Profile of Women Veterans Administration Outpatients Who Report a History of Sexual Assault Occurring While in the Military

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a heart attack within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

Medical Care Needs of Returning Veterans with PTSD: Their Other Burden

ABSTRACTBACKGROUNDThere has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.OBJECTIVES(1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD.DESIGNCross-sectional study using existing databases (Fiscal Year 2006–2007).SETTINGVeterans Health Administration (VHA) patients nationally.PATIENTSAll 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC.MEASUREMENTS(1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality’s Clinical Classifications software framework).MAIN RESULTSThe median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (pu2009<u20090.001), and for men was 5.0 versus 4.0 (pu2009<u20090.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC.CONCLUSIONSBurden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.

Health status among 28,000 women veterans. The VA Women's Health Program Evaluation Project.

AbstractBACKGROUND: Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.n OBJECTIVE: To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.n DESIGN AND PATIENTS: Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.n MEASUREMENTS: Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).n RESULTS: In each age stratum (18 to 44, 45 to 64, and ≥65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged≥65, mean MCS was better for women than men (49.3 vs 45.9, P<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.n CONCLUSIONS: Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.

The exclusion of non-english-speaking persons from research

AbstractOBJECTIVE: We sought to determine how often non-English-speaking (NES) persons are excluded from medical research.n DESIGN: Self-administered survey.n PARTICIPANTS: A Medline search identified all original investigations on provider-patient relations published in major U.S. journals from 1989 through 1991, whose methodologies involved direct interaction between researcher and subject (N=216). Each study’s corresponding author was surveyed; 81% responded.n MEASUREMENTS AND MAIN RESULTS: Of the 172 respondents, 22% included NES persons; among theseincluders, 16% had not considered the issue during the study design process, and 32% thought including the NES had affected their study results. Among the 40% who excluded the NES (excluders), the most common reason was not having thought of the issue (51%), followed by translation issues and recruitment of bilingual staff. The remaining 35% (others) indicated that there were no NES persons in their study areas.n CONCLUSIONS: NES persons are commonly excluded from provider-patient communication studies appearing in influential journals, potentially limiting the generalizability of study findings. Because they are often excluded through oversight, heightened awareness among researchers and granting institutions, along with the development of valid instruments in varied languages, may increase representation of non-English-speaking subjects in research.