Healthcare/Healthscare: A Study of the U.S. Veterans Administration

Table of Contents: 

    INTRODUCTION

    On June 9th of 2014, fifty-seven thousand veterans were still waiting to receive their initial appointments at the Veterans Hospitals. The United States stood in shock as Americans learned about the lack of quality health care provided to veterans. Even more horrifying was how soldiers were dying while waiting for health resources at the Phoenix Veterans Administration hospital (Bronstein & Griffin, 2014). This scandal rocked the nation in the spring of 2014, and made Americans rethink the ways in which veterans receive support through the government. The United States of America is a country rich in resources; it touts a foreign direct investment (FDI) of 180 billion dollars, and spends 560 billion dollars a year on its military (Forbes, 2013) which is about 4.35% of its Gross Domestic Product. (CIA Fact Book 2012). Yet with all of the financial resources available to the military we have failed the critical component: the soldier.

    Although America is a patriotic country dedicated to the military men and women who serve our country, we have rejected the soldiers that fought to preserve it because we have failed to provide the necessities for a decent quality of life.  So how did we get to this place? The veteran healthcare facilities are inadequately managing the care of soldiers. There is a lack of oversight on the operational, and administrative side of veteran’s affairs, as well as a blatant disregard for the health maintenance and well- being of our soldiers. (GAO, 13-130 2013)  Why was there not more concern for the welfare of the soldier by the administrative staff, the doctors, as well as the executive structure? One example by the GAO report revealed, four clinics across three VAMCs did not use the electronic wait list to track new patients that needed medical appointments as required by VHA scheduling policy, putting these clinics at risk for losing track of these patients (GAO-13-130, 2013). What are the effects of all this mismanagement and dysfunction?

    Some of the effects were longer than average wait times, outdated and inefficient scheduling system, gaps in scheduler and provider staffing, including issues with telephone access (GAO- 13-130 2013). Other effects were barriers to care which included, punitive empathy and forced readiness (Ray, 2013). What does this convey to our soldiers, and more importantly, what message does the inadequate healthcare of our soldiers convey to the nation?

    Disparities with healthcare are a social problem that should be of great concern to all of us, because one brave enough to fight for one’s country should at least be expected to receive quality health care services. No American should die waiting for an appointment. (Robbins 2014). Falsification of patient records should not be how we measure quality of care. Government Accountability Office (GAO, 2013). Functionalist theorist would say that the failure in the health of our veterans serves a purpose in our society. The veteran health administration functions as a system (literally) social solidarity being a key component (Durkheim, 1969). The failure of the VA calls for a change in approach to how veterans’ affairs have formerly been handled. Disorganization in the system leads to change because societal components must adjust to achieve stability. When one part of the system is not working or is dysfunctional, it affects all other parts and creates social problems, which leads to social change (Durkheim, 1969). The Veteran Healthcare System is the oldest and the largest healthcare system in our nation (V.A. Gov 2012), and schedules almost 18.5 million veteran patients a year. (V.A.OIG 2014). All must be concerned that the institutions society relies upon to care for our veterans are providing our veterans with quality health care; moreover, we must ensure that if they are not, then we must address the problems in administering care, and most importantly the solutions.

    The primary focus of my research is the inadequacies of the Veterans Health care facilities in the United States. Key points of focus are the health of the veteran, the health of the system and the health of families of the veteran. The goal of this research strives to give voice to the struggles veterans face in daily life, in hopes to bring much needed awareness to the issues facing our veterans. I addresses the broken administrative processes at V.A. facilities, including inordinate wait times for appointments and scheduling, in addition to the improper use of Veteran Administrative policies and guidelines which serve to hamper adequate care. (Government Accountability Office GAO Report 2013).  As a nation we say we hold our soldiers with high regard; however, the research and data have shown this is not the case. The quantitative results of Boyko, Maynard, (2006) show how we have fallen short of administering quality healthcare.

    Boyko utilizes correlation examination and logistic regression to reveal shortfalls in the functionality of the veteran healthcare system. Findings show that of the VA healthcare users, the VA has a socially disadvantaged and less healthy population. (Boyko, Maynard 2006). This revelation leads us to question the symbols we actually care about within our society, symbols such as the flag that "The colors of the pales (the vertical stripes) are those used in the flag of the United States of America; “White signifies purity and innocence, Red, hardiness & valor, and Blue, the color of the Chief (the broad band above the stripes) signifies vigilance, perseverance & justice”, (Thomson, Charles 1782). We cherish the symbol, but dishonor our veterans by not administering the same precepts upon them. Logistic regression shows the health of veterans; however, families suffer alongside veterans as well.

    Families and veterans suffer with adjustment. Most issues stem from problems with engaging significant others, and health related quality of life issues. For example soldiers reported one or more mental barriers experienced in day to day life such as fear, embarrassment, and stigmatization (Singh et al, 2005). Durkheim argued that complex societies are held together by social bonds which are strong among members of industrial societies (1893). These social bonds have been fractured for soldiers due to war, conflict, and an inability to cope with the civilian world upon their return. Adjustment is also addressed in the work of (Sherman et al, 2008).

    Sherman et al. (2008) saw interpreting significance as a critical tool in evaluating the effect that the breakdown of the Veterans Administration had on the veteran. The study examines the effects on veterans and on the families. Sherman used content analysis and manual coding to examine decision-making strategies of PTSD families and to explore other potentially efficacious engagement strategies, in an attempt to establish a better understanding, (Sherman et al. 2008) These issues are extremely important, and have been thoroughly covered in my review; however, I have chosen as my contribution to this research to focus on the source of care for veterans.

    THEORETICAL REVIEW

    The major points in this research aim to help create more productive processes between the Veterans Administration, the soldiers (veterans), and family members of veterans. This review will highlight the struggles and complexities facing veterans. The central focus will be on the Veterans Administration with key issues such as the health of the system, scheduling processes, as well as the systemic failures in the Veterans Administration operating procedures the health of the veteran, adjustment issues, and barriers to care, and finally the health of the family, which will address health-related quality of life issues as well as coping strategies. The objective of this research is to address the effects of struggling veterans, the broken system, as well as fractured families. For my contribution, I hope to ascertain if the quality of care for the veteran increased or decreased depending on where veterans received their care. The goal is to have a better understanding of the complexities on how all the components of veteran healthcare work separately, but more importantly: how they can work together. My hope is that this project will contribute to the conversation of veteran healthcare, create more meaningful ways to improve it, and expand the need for future research.

    Health of the Veterans

    The majority of research surrounding veteran healthcare focuses on the effects from conflict, primarily from the Iraq and Afghanistan wars. These wars’ long duration, coupled with military procedures called “stop-loss policies” that keep service members enlisted long beyond their contractual end-dates, have profoundly stressed veterans, their families, and the healthcare system. (Ray 2013). The most common effect is Post Traumatic Stress Disorder (PTSD). As of September 2014, there were about 2.7 million American veterans of the Iraq and Afghanistan wars, from that a population survey of 103,788 veterans 13% of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) were diagnosed with PTSD. (Richardson et al. 2011). PTSD diagnoses had been obtained through the use of electronic medical records.

    Holowka et al. found a correlation between databases diagnoses, which are electronic recordings from the Department of Veteran Affairs EMR (Holowka et al. 2014). The EMR’s are an electronic recording of military members’ medical records. For the V.A., an affirmative PTSD diagnosis is determined by a standardized diagnostic interview. Holowka conducted their study using the SCID (Structured Clinical Interview DSM-IV), which are semi-structured interviews conducted with the veteran used to determine personality disorders. Their results showed a discrepancy in reporting of (72.3%) for current PTSD and (79.4%) for lifetime PTSD and attributes these discrepancies to inaccurate diagnoses, due to the insufficiencies of the EMR (Holowka et al. 2014). These discrepancies lead to inappropriate treatment; diagnostic errors in medicine which contributed to inefficient or inappropriate treatment, poor use of resources, and can also result in patient harm. (Newman-Toker & Pronovost, 2009). Miscalculations hamper the effectiveness of treatment for veterans. Equally significant to Holowka’s findings are the barriers to care that Ray revealed in his article.

    Using qualitative in-depth interviews Ray (2013) found that soldiers suffered severe PTSD after returning home from war, but many were reluctant to seek the much needed help. He attributed their reluctance to forced readiness, which is a training method of having soldiers fit for combat duty as soon as possible in order to complete mission objectives. Soldiers also reported the organizational structure of the military as a barrier citing stop-loss policies. Stop-loss refers to the act of keeping soldiers in combat-zones for longer periods than their contractual obligation (Ray, 2013). Another barrier is the, “you’re finished you’re done” attitude from the military (Ray, 2013). The “you’re finished you’re done” discourages soldiers from seeking treatment because outwardly, the military encourages soldiers to seek treatment; however, the repercussions soldiers suffer when treatment is sought is negatively reflected in their professional career. Many veterans face the paradoxical issue of needing treatment while also needing to be combat-ready. One cannot be deemed combat-ready while suffering from post-traumatic stress. The author found that the Veteran’s Administration created a myriad of new programs, such as mandatory post-deployment mental health screenings, as well as initiatives that focused on more patient-centered care. A primary example is a new technology to provide care, coined “tele-health” which is a rapid access to shared and remote medical expertise by means of telecommunication and information technologies to deliver health information for the purpose of improving patient care. (V.A. OIG 20011). This is but one of the new programs set up to ease traditional barriers (Ray, 2013). The author makes a critical note of the report from the Institute of Medicine at the National Academy of Science (INMAS) which states how,” it is too soon to ascertain the certainty of these programs effectiveness”(Ray, 2013). What we do know is that the amount of soldiers returning will increase, and if there is no certain remedy for the strain already weighing upon the V.A.; the struggles that veterans’ face regarding these barriers to care will only increase. This work is significant to research conducted about veteran services because it gets to the heart of the matter, which are barriers that stifle and prohibit immediate healing for the veteran. Ray (2013) revealed the barriers for soldiers, but others focused on restoration for veterans.

    Work by Litz (2012) underscores the needs of the veteran by specifying three critical steps towards meaningful and restorative help. Litz emphasizes the need for Critical Incident Stress Debriefing (CISD). CISD is an immediate psychoeducational single session that utilizes stress management and trauma-sharing tools for soldiers who have just (1 to 2 days) returned from combat zones. (Litz, 2007). Another tool utilized was Cognitive Behavior Therapy (CBT). CBT consist of repeated and sustained emotional disclosure of traumatic incidents over multiple sessions, in order to evaluate efficacy, and self-monitoring in hopes to promote new learning (Litz, 2007). Lastly, Litz proposed psychological first aid whose goals include providing nourishment, rest, and screening for soldiers who suffer severe psychiatric decompensation, suicidality, and homocidality during or immediately after combat. Her three- pronged approach is the framework for a much needed early intervention process to help transition soldiers in a productive and worthwhile manner (Litz, 2007). The operationalization of PTSD or TBI is complicated. Trauma affects soldiers in many ways and at different times, and several factors play a role in a soldier’s ability to manage trauma. Utilizing resilience research, (CBT), (CISD), as well as psychological first aid Litz assessed processes and outcomes, suggesting that individual and social resources can be used to manage post traumatic demands to find meaning, purpose, and hope. The goal is to reduce or eliminate current adversities and stressors and derive positive feelings (Litz, 2007). There is still much work to be done in addressing the issue of PTSD, and TBI, and learning to manage the health of the veteran is the first line of defense.

    Health of the system

    The administrative body of The Veteran Healthcare System is structured like most private hospital systems; at the top is the Veteran Integrated System Network (VISN), whose duties entail providing oversight, management of and taking responsibility for regional budget, implanting alliances with such other governmental public and private health care organizations, and to develop systems that provide a safe and effective delivery of health care (V.A. GOV, 2013). The Veterans Administration Medical Centers (VAMC) is a hospital that provides primary, specialty, and long-term care services to the veteran population. (VA GOV, 2013) Lastly the Veterans Health Administration (VHA) which is the federal agency charged with administering benefits provided by law to the veteran. (VA GOV, 2013). The health of the system is pertinent to this research because it addresses the institution. The Veterans Hospital is the first contact point for veterans seeking treatment, and the primary location where veterans receive their healthcare: veterans need to know that this is a place of help that they can trust. A study conducted by the United States Government Accountability Office (GAO) researched the actual processing of veterans prior to treatment in V.A. healthcare facilities (GAO, 2013). Specific points of interest in their study included: (1) the extent to which VHA approach for measuring and monitoring medical appointment wait times reflects how long veterans are waiting; (2) the extent to which VAMC are implementing VHA policies and processes for medical appointment scheduling, and any problems encountered in ensuring veterans’ access to timely medical appointments as identified by VAMC; and (3) VHA initiatives to improve veterans’ access to medical appointments. (GAO 2013).  The primary findings revealed serious issues concerning how VHA and VAMC evaluate and examine wait times, including appointment availability, desired availability, and recorded availability by schedulers (GAO 2013). Audits conducted showed discrepancies in the implementation of scheduling procedures (GAO, 2013). Many of the wait times were fixed to accommodate favorable ratings on individual facilities in order to conform to VHA performance goals (GAO, 2013). Some employees were not trained or certified for use of (VistA); a policy mandated by VISN as well as VAMC, and the VHA (GAO, 2013). Veteran Health Information Technology Architecture (VistA) is the (dated) computerized system the military uses to install, monitor, and retain all veteran medical records electronically.  By May 2010, the VistA scheduling system is antiquated, and is at least 25 years old, and ineffective in facilitating care coordination between different sites.  In 2000, the VHA attempted to upgrade the system and give it the much needed modernization; however, project mismanagement and lack of oversight halted the project. (GAO 13, 2011). Today, congressional hearings and tight restrictions keep close watch on V.A. guidelines and personnel. Congress has approved 29 million dollars for the overhaul of VistA with a caveat: “The Veterans Administration will not be allowed to spend more than 25% of its funding until it submits a detailed budget to the relevant Congressional committees” (GAO13, 2011).  The appropriation bill opined, “There is rising concern the Departments will spend years and billions of dollars on their own electronic health record systems and lose sight of the end-goal of an interoperable record,” (GAO-13, 2011) This underscores the deficiencies with the system. The issues with wait times are problematic, and coupled with the misuse of the VistA scheduling system create another set of problems for veterans to contend with (GAO, 2013).   Ray’s (2013) article also addresses the administrative problem with the system, and cites it as “initial contact”.

    In 2007, the Washington Post reported that Walter Reed, the nation’s premier Veterans Affairs hospital, was “systematically failing” (Washington Post, 2007). The Inspector General for the Department of Veterans Affairs’ released findings that showed veterans were waiting an average of three months for their preliminary screenings. (DOD VA. Gov. 2008). In his interviews Ray (2013) contends that not only do veterans have to cope with forced readiness, punitive empathy, as well as reintegration hurdles; they must also deal with a bogged down dysfunctional healthcare system. Other researchers also conducted interviews to ascertain barriers to care.

    Elnitsky et al. (2013) interviewed veterans from OIF (Operation Iraqi Freedom) and OEF (Operation Enduring (Afghanistan) Freedom). Out of 359 veterans, two-thirds reported one or more mental barriers experienced in day to day life such as fear, embarrassment, and stigmatization. Strikingly 15% of veterans had concerns about healthcare staff and their reputation for care, and 26.7% reported wait times as a barrier to care (Elnitsky et al, 2013). The use of electronic wait list, recall/reminder software, medical appointment schedule availability, and oversight of VHA’s scheduling policy were also concerns. Auditors found that in some facilities schedulers were not using the required software at all (GAO-114, 2013). Many were recording appointments with pen and paper, and later transcribing the information into VistA, a violation of procedure, as well as misuse of patient information according to VAMC and VHA guidelines (GAO-114, 2013). Several staff were found to have scheduled or rescheduled patient appointments, a tactic known as “blind” scheduling without any communication with the patient. (GAO-110, 2013) The electronic wait list established to keep track of new patient’s with whom the clinic has no standing relationship with were not being used. Staffs had reverted to giving client paper follow-up appointments because consults were stacking up, and the electronic wait list was ineffective (GAO-110, 2013). The relevance of this research reveals the need for a meaningful overhaul and much more diligent oversight to the Veteran Healthcare system. The ineffectiveness of less stringent clinical assessments, dated standardized instruments which miss critical evaluations, and poor use of VistA reduce the likelihood of a veteran returning to the V.A. hospital for the necessary care. (GAO 2013, 110). The outcomes of the studies outlined show failures in the system, and underscore the need for reforms, providing an even stronger basis for future research. This study should be used to help guide the direction of any future research, which measures the quality of care at military hospitals.

    Health of families

    There is limited research on how the inadequate care of the veteran and the dysfunction of the Veteran Healthcare system effects families. The health of families is relevant to my research for it seeks to represent a demographic whose voice has been ignored.

    Erbes et al. (2011) conducted an empirical longitudinal study focused on couple adjustment and post-traumatic stress disorder. Much of the assumptions surrounding PTSD have been seen as an intrapersonal disorder, which occurs when there is a problem with the internal process of communicating with oneself. Some symptoms include nightmares, intrusive memories and flashbacks (Erbes et al, 2011). However, many miss the interpersonal context in which it occurs; especially within the family setting. Many veterans who return from combat experience significant and immediate problems within their intimate relationships. There is increased irritability, anger, and hyper-arousal. (Erbes et al, 2011). There are social factors that play an important role in PTSD recovery, and reintegration is most significant. The most common stressors during reintegration are negative social interactions and life events, which extensively deteriorate social support and increase the risk of PTSD (Brewin et al. 2000). The Structural Equation Model (SEM) was used to examine relationships between PTSD symptom factors and relationship adjustment. Their findings concluded of the (n=54) 17% screened positive for PTSD, and of those who screened positive they reported a notable lessening of adjustment in their relationship. Some of the symptoms attributed to poor relationship adjustment are emotional withdrawal, lack of emotional involvement, and decreased capacity for positive engagement (Erbes et al. 2007).  Structural equation models examine relationship adjustment and the symptoms that impede success, but Litz (2007) found that early intervention is critical for couple adjustment for veterans struggling with PTSD.

    Research by Litz (2007) states that early interventions are crucial, for they are most effective when social supports for veterans who suffer from PTSD are evaluated systematically. The span and depth of social supports, such as spouses and family members involved in the recovery process are critical for the veteran in the coping and managing of the daily requirements of social life (Litz, 2007). Early interventions help assists the individual with anticipating problems in using their support system. Litz proposes that utilizing early intervention techniques to assess the relational stability of veterans is tantamount to quality of life for veteran health (2007). Litz research focuses on intervention while Singh et al (2005) presents the risks to the veteran’s quality of life.

    Health related quality of life (HRQL) concerns presents risk to families and are relevant for they give future predictions to longevity of life and quality of care. The care of a specific group of veterans was evaluated from October 1997 to March 31, 1998. (Singh et al, 2005). The purpose of this study was to evaluate the health of the veteran population who received care in Upper Midwest V.A. facilities. The veteran populations at these facilities represent outcomes of the health status of veterans who received inpatient and outpatient care at VISN. Their results revealed that veterans in that population incurred substantial shortfalls with physical and mental morbidity rates (Singh et al, 2005). Physical morbidity rates are an awareness of the departure from physical well-being due to illness, injury or sickness. Mental morbidity is the departure from mental acuity due to injury or illness Singh et al. (2005). Additionally, the veteran population within this specific network experienced higher than average Active Daily Living Limitations (ADL) and experience Health Related Quality of Life (HRQOL) that is significantly worse in the physical and mental sphere than that of the general U.S. population (Singh et al, 2005). Characteristics of responders were a mean age of 64.5. Of that age group 95.8% were men, 95.8% were white, 64.9% were married, 28.2% had less than a high school education, and 37% were unemployed. Singh et al. (2005) There were more marked results clinically for Physical Competent Summary) (PCS) than Mental Competent Summary (MCS), which suggest that, although veterans have greater physical and mental morbidity than the general U.S. population, physical morbidity is far greater (Singh et al, 2005). This study of HRQOL was useful for obtaining the long term repercussions, and in identifying broad patterns in the Veteran healthcare system for veterans who had already received treatment in V.A facilities; however, the lack of comprehensive data on families, especially children of veterans reveals the need for more studies, and should fuel the push for future research.

    Summary of Literature Review

    My theoretical review has highlighted critical areas for concern such as the struggles and complexities facing veterans, the systemic failures in the Veterans Administration operating procedures, as well as the effects that these struggling veterans and this broken system have on families. The information in this review provides an in-depth look at these concerns; however, it also reveals the urgent need to expand the conversation on veteran health. Future studies must include more comprehensive research surrounding the overall health of our veterans, the health of the system and the health of families. While quantitative data is useful in predicting outcomes, in order to move forward future studies must utilize more qualitative research that endeavors to ask the most pertinent why.

    Methodological Review

    During my research I highlighted three methodological themes, in-depth interviews, Structured interviews and, secondary data analysis, which is the implementation of existing data ascertained from prior research.

    In-Depth Interviews

    Ray utilized grounded theory to arrive at conclusions of veteran health. Ray (2013) applied an unstructured in-depth interview technique to find meaning for soldiers who experience PTSD. He asked respondents to give what they thought were the most significant reason as to why soldiers are reluctant to seek help.  Soldiers were interviewed individually, and all expressed different issues related to their PTSD. The concept of barriers to care evolved which Ray (2013) gave voice to in his article. Ray categorized these experiences and noted specific barriers such as forced readiness, the organizational structure of the military, and you’re finished you’re done. While Ray utilized qualitative methods, others chose a more structured approach.

    Howloka et al. (2014) chose semi-structured clinical interviews in order to identify patterns and relationships of PTSD. Diagnoses were extracted from the Department of Veterans Affairs Electronic databases to see if they were in concordance with the Structured Clinical Interview Diagnostic (SCID) Module. This method was employed to rival the traditional Electronic Medical Records (EMR) used by the military to obtain vital health information about the soldier. Many of their subjects also completed self-report and other interview based measures. Researchers measured relationship satisfaction as well as relationship adjustment using the GINNI Coefficient, which is a tool used for statistical dispersion to measure inequality. With the increased availability of Problem List and administrative data, the odds of these data being used to inform policy decisions is uncertain, highlighting the importance of continued attention to integrity and accuracy of these data. (Holowka et al, 2014). while both Ray and Howloka used interviews Erbes and Litz used quantitative measures to evaluate veteran health.

    Erbes et al. (2011) used content analysis to measure binary variables in order to understand couple adjustment for veterans with PTSD. Researchers provided quantitative data compiled from several surveys from soldiers as part of a longitudinal study separated as Time 1 and Time 2. Questionnaires were given which assessed deployment and post deployment experiences and functioning (Erbes et al, 2011).  A 7-item version of the Dyadic Adjustment Scale ( Spanier, 1976)  was used as a brief measure of relationship adjustment. Binary variables were used for gender, marital status (married/cohabiting vs. not), and rank (officer vs. non-officer). Education was coded as an ordinal variable. results revealed Seventeen percent of the sample ( n = 54) screened positive for PTSD at Time 1., and soldiers screening positive for PTSD reported significantly poorer relationship adjustment on all measures at both time points  The results provide valuable insight on the perspectives of the soldier pre-and post-deployment, and confirms results in other studies about the prevalence of PTSD. Utilizing empirical longitudinal methods would be of added value in my research to obtain information on how veterans actually feel over time about the care they actually receive.

    Secondary Data Analysis

    Litz employed secondary data analysis by critically reviewing peer reviewed randomized controlled trials (Litz, 2007).All studies used standard, well-accepted self-report outcome measures, and several studies used state of the art structured clinical interviews to evaluate PTSD, which allowed for independent blind assessment of outcomes. Determining whether the correlations followed the theories presented was tantamount to this research. Although debriefing research is in its infancy as it relates to PTSD; there is no sufficiently valid evidence from uncontrolled or quasi-experimental studies of early intervention to suggest that the intervention promoted recovery to a greater degree than would have occurred with the passage of time.( Litz et al. 2007). The instrument Litz used for the survey was a four-page computer-scored self-administered questionnaire consisting of three major components. The goal of this method was to explore new ideas about the effects of cognitive behavior and early intervention processes on soldiers with PTSD (Litz, 2007). Variables such as age, race, and marital status were examined for use in the VA population. A logistic regression was used to analyze the presence of any hospitalization for each of the individuals in the survey. Conclusions were mixed on outcomes due to uncertainties of risk factors associated with (a) the optimal time frame to provide early intervention, (b) the process of change, (c) the specific change agents, (d) the type of post intervention behaviors that promote recovery and maintenance of change, (e) and also the optimal mode and method of screening for various types of PTE. Litz (2007). In the study done by Boyko, Maynard (2006) for the U.S. Department of Affairs, researchers performed chi-square statistic for categorical variables, and the two sample t-test for continuous variables. They also used logistic regression to determine the association between these two factors (alcohol, and or drug induced deaths) after adjusting for demographic. Their purpose was to explore whether veterans who use Department of Veteran Affairs (V.A.) are sicker than veterans who do not. (Boyko, Maynard 2006). Results of their study showed that after adjusting for differences between users and nonusers of VA, healthcare services did not appreciably change the observed association between cause of death and use of VA healthcare services for either females or males (Boyko, Maynard, 2006).  The United States Government Accountability Office did not collect aggregate data on the administrative inconsistencies; however, researchers did interview several facets of the V.A. administrative departments. The results of the data collected  show a great need for oversight and helped GAO inform the Department of Veteran Affairs of the tools needed to incorporate research outcomes into clinical practice guidelines and procedures(Boyko, Maynard 2006). These tools could help to identify and improve the needs of soldiers who suffer from PTSD. 

    RESEARCH PLAN

    Before beginning this research I made sure that a strict code of ethics was adhered to by obtaining a certificate of completion from the National Institute of Health (NIH) Office of Extramural Research for completing the training course on “Protecting Human Research Participants”. I began my study by selecting a specific population. My population of interest is comprised of military veterans in the United States. The participants accessible to this study are veterans. Veterans was classified as those who have served, and completed at least two years on active duty.  The study included 239 participants which were selected from the National Longitudinal Study of Adolescent and Adult Health Data set (ADDHEALTH). The population was randomly selected, and was not representative of the general population. My first objective was to explore the source of care for veterans. In order to do this I examined the results of those veterans who reported using military hospitals for their source of care. Secondly, I wanted to determine if the quality of care increased or decreased according to where the veterans received their healthcare?  The dependent variables I used were 1.) Where do you usually go when you are sick, or need health care? 2.) Was there a time you thought you should have gotten care but did not, and 3.) When was your last routine checkup? Due to limitations participant constraints on the question of, (did health problems get worse because of delayed care) was only used when people had health problems.

    STUDY VARIABLES

    In addition to veteran status and source of care, I obtained data from the ADD Health data set to control for age, gender, and race.  The population was randomly selected, and was not representative of the general population. Gender was coded as H1GI6B BIO_SEX where (1=1) for male and 0= female. Age was coded as H4OD1 (age=2014) H1GI6B. The median age for the veterans was 35. Race was coded as (HIGI9=1) (Hispanic=0), and White=1. The table of descriptive statistics below shows the mean, standard deviation, the minimum, as well as the maximum in order to identify users of VA healthcare services.     

    Table 1: Descriptive Statistics for Variables Used in Study

    RESULTS

    In determining whether the quality of care for veterans who used VA hospitals increased or decreased the results revealed that of n=239 : has there been a time in the last 12 months that you should have gotten care but did not, 69.10% of males should have gotten care, but did not; 90.9% of those respondents were of the median age, and 74.00% were white. Of the respondents asked, in the past 12 months did a health problem get worse because you did not get care when you thought you should; 90.9% were male; 64.10% were of the median age, and 86.50% were white. During the logistical regression limitations were placed on this result due to poor reporting. For the variable (in the past 12 months did a health problem get worse because you did not get care when you thought you should) 185 respondents were missing, and only 54 gave valid responses for those whose health worsened. For the respondents that were asked if they had a routine check-up in the past 12 months; 73.2% were male, 38.90% were of the mean age and 32.90% were white. These findings reveal that as the median age increases veteran respondents who do not receive annual checkups at the Veterans Hospitals are more likely to have worsened health, and are also more likely to not get care when needed. 

    Figure 1 gains of 2.1 percent (|t|=2.09, p<0.05).

    Table 1: Impact of Receiving Care from a Military Hospital or Clinic on Three Key Outcomes, controlling for Demographic Characteristics. Odds Ratios from Logistic Regression.

     

     Received Routine Check

    Health Worsened

    Did Not Receive Care

     

    Received Care from Military Facility

    8.466***

    1.368

     0.753

     

    (0.374)

    (0.639)

    (0.334)

    Male

    0.359*

    1.104

    1.200

     

    (0.475)

    (0.970)

    (0.459)

    Age

           1.088

    1.105

    0.989

     

          (0.098)

    (0.215)

    (0.099)

    White

            0.732

    0.888

    1.569

     

           (0.319)

    (0.700)

    (0.340)

    Constant

           0.141

    0.11

    0.309

     

          (3.500)

     (7.639)

    (3.545)

    Observations

          239

           54

          239

    R-squared

    0.194

    0.008

    0.014

    Standard Errors in parentheses: + significant at 10%; * significant at 5%; ** significant at 1%;

    *** significant at 0.1%

     

    NOTES:

    Receive Routine Care means: Received an annual check-up with in the last 12 months

    Health Worsened means: Health got worse because of delayed care.

    Not Care means: Should have gotten care in the last 12 months but should did not.

    SOURCE: National Longitudinal Study of Adolescent and Adult Health 2008

    Note for table: 1st column those who received care from a military facility were 8.4 times more likely than those who did not receive care from a military facility to receive a routine check.

    Note: men are 64.1% less likely than women to receive a routine check.

    (1- 0.359=-0.641)

    Age and race were not significant for those who received care.

    Impact for Those Who Received Annual Routine Checkup

    Figure 1 depicts the outcomes of the logistical regression model that show the effects of whether or not getting a routine annual checkup increases or decreases quality of care. The outcome revealed that 78.4% of veterans received their annual checkups. This finding was significant in that it showed a p<.000).

    Impact: on Whether Health Worsened

    Figure 1: Column two  whether the veterans’ Health got worsened explain in methods

    Notes: it would appear that those who receive care from a military facility are 36.8% more likely than those who receive care elsewhere to have worsened health; however, this results is not statically significant (p=0.624). None of the other values showed any significance.

    Impact: Should Have Gotten Care but Did Not

    Again the results show (p=0.395) that none of the variables were significant for the outcome of should have gotten care but did not. For my key independent variable: received care from a military facility, of those who received care from here outcomes show that of veterans who were just as likely to have gotten care but did not were 24.7%.

    CONCLUSION

    Based on the ADDHEALTH data set, as well as undiagnosed issues, to include the limitations placed on the outcomes I was surprised at the findings. From previous research in my literature review, and with all of the negative attention on the Veterans Administration I expected that there would be decreased usage of V.A facilities, poorer health conditions for veterans who use military hospitals, or at the very least poor health reporting. What I found was that veterans who  routinely receive their annual checkups at a military facility are 8.4 times more likely to get routine check-ups than veterans who use other facilities. Female veterans are 35.9 times more likely than male veterans to get annual check-ups: however, for those who received care age nor race were significant. Oddly this disputes the findings of Holowka et al, (2014) which showed a decrease in the use of Veteran Hospitals due to care concerns. The Veteran Health Administration is the largest and the oldest healthcare system in the United States. It is also the primary source of health care for our veterans. The V.A. must conform to the rapidly changing landscape of technologically centered patient care in order to effectively serve its population. It must push to embrace the rapidly changing world of healthcare by embracing new technologies such as telehealth, and implement structural changes administratively. The Veterans Administration must  provide effective oversight of its administrative and executive staff to ensure application of proper protocols with on-site report and repair, as well as annual inspections of individual sites. Research must play a critical role in developing new ideas to ease transitions and remove barriers to care for the soldier. Qualitative studies are imperative for they capture real-time, real-life struggles for veterans. There must be significant change in how we approach the health of the veteran, the health of the system, and the effects that both have on families, or the blot on the V.A. will become a stain on our nation. My theoretical review has highlighted critical areas for concern such as the struggles and complexities facing veterans, the systemic failures in the Veterans Administration operating procedures,  the effects that these struggling veterans and this broken system have on families, and whether the source of care effect the quality of care for the veteran. The information in this review provides us with an in-depth look at these concerns; however, it also reveals the urgent need to expand the conversation on veteran health. Future studies must include more comprehensive research surrounding the overall health of our veterans, the health of the  system and the health of families, and while quantitative data is useful in predicting outcomes, in order to move forward future studies must utilize more qualitative research; research that endeavors to ask the most pertinent why. Much of the previous research did not focus on interpreting cultural or historical significance, a must when studying issues dealing with the military. More effort must also be put on giving voice to not only the veteran, but also the spouses and the children who suffer alongside the soldier. I believe that I made a significant contribution to this issue. I found that much of the misgivings about the use of the Veteran Administrative Hospitals was just that, misgivings. My research gave me a different outlook for the future of veteran interactions with the V.A.; it also helped propel me in a direction of focus for my graduate studies, for this alone I have benefitted greatly, and hope that others may as well.

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