1. Utilization of VA, Military, and Community-Based Care among Iraq and Afghanistan Veterans with PTSD Erin P. Finley, PhD MPH South Texas Veterans Health Care System Assistant Professor, UT Health Science Center, San Antonio

2. Disclosures The presenter has no financial relationships to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. Neither PESG, AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity. PESG and AMSUS staff has no financial interest to disclose. Commercial support was not received for this activity.

3. Learning Objectives: At the conclusion of this activity, the participant will be able to: 1. Describe the spectrum of available PTSD care services for veterans. 2. Explain factors associated with veterans’ use of VA, military, and community-based services for PTSD care. 3. Discuss implications of patterns in care-seeking for tailoring services to more effectively meet the needs of service members and veterans with PTSD.

4. Acknowledgements Funding: PPO 13-163, “Veterans’ Care Access and Preferences for PTSD Treatment in the Community” (VA Health Services Research & Development Service) Collaborators: Michael J. Mader, MS Mary Bollinger, PhD MPH Elizabeth K. Haro, BS Mary Jo Pugh, PhD RN Hector A. Garcia, PsyD Jacqueline A. Pugh, MD The views expressed in this presentation are solely those of the author(s) and do not represent the views of the Department of Veterans Affairs of U.S. Government.

5. Study Background 18-20% of OEF/OIF Veterans affected by PTSD Evidence-based practices for PTSD Available DoD/VA nationwide Not consistently available in community Service-connected veterans have options What choices are veterans with PTSD making?

6. Study Objectives Measure PTSD-care utilization patterns of veterans Compare characteristics of veterans across the different utilization groups Compare stated preferences, perceived care needs, and perceived barriers Understand patient-level factors associated with PTSD care utilization

7. Fortney et al, State of the Art Model

8. Population Sampled All Veterans in TXOEF / OIF / ONDService-connected, with PTSD N = 27,451

9. 1124 selected for survey Sex Any VA care FY12/13 Rurality 9 Stratification by: Data Collection Method

10. Survey Content Demographics and Military Service Financial Factors Healthcare Usage / Need Care-Setting Preferences Perceptions about Barriers

11. Survey Response Modified Dillman method to increase participation -Mailed invitation with online link/hard copy -Second mailed letter with online link/hard copy -Reminder letter -For respondents, thank you letter with $20 gift card n = 237 (26.9% response rate)

12. Analysis Responses weighted: stratification / response rate Four utilization groups based on PTSD care setting One-sample Z-test of proportion Multinomial logistic regression model

13. Utilization Groups Where PTSD care was received, last 12 months: VA only Non-VA only (DoD or community) Dual Care (both VA and non-VA) No Professional PTSD Care 57% 9% 14% 20%

14. Sex

15. Rurality

16. Use of VA Care

17. Age

18. Ethnicity/Race

19. PTSD Severity

20. Model Design SexRurality AgeEthnicity/RaceEducation Rank Marital StatusTotal Time Deployed Demographics IncomeEmployment Status Non-VA PlanWorried about Housing Financial Self-AssessmentPCL Score Use VA for any carePast Utilization for PTSD Health Factors VA DoD Community Preferences MedicationGroup Therapy Stigma Talk TherapyUnderstanding Threshold Barriers

21. Predictive Significance of Factors Variable Namep-value Sex ns Rurality ns Age ns Ethnicity/Race<0.0001 Education Level<0.0001 Rank 0.0010

22. Education Level

23. Highest Rank

25. Predictive Significance of Factors Variable Namep-value Sex ns Rurality ns Age ns Ethnicity/Race<0.0001 Education Level<0.0001 Rank 0.0010 Income<0.0001 Employment Status ns

26. Income

27. Employment Status * *

28. Predictive Significance of Factors Variable Namep-valueVariable Namep-value Sex nsUse VA for any care 0.0242 Rurality nsPCL score 0.0047 Age nsnon-VA Health Plan<0.0001 Ethnicity/Race<0.0001Eligible for DoD care 0.0015 Education Level<0.0001 Rank 0.0010 Income<0.0001 Employment Status ns

29. Insurance/Eligibility 29

30. Predictive Significance of Factors Variable Namep-valueVariable Namep-value Sex nsnon-VA Health Plan<0.0001 Rurality nsEligible for DoD care 0.0015 Age nsUse VA for any care 0.0242 Ethnicity/Race<0.0001PCL score 0.0047 Education Level<0.0001Ever had DoD care for PTSD ns Rank 0.0010Ever had VA care for PTSD<0.0001 Income<0.0001Ever had comm care for PTSD 0.0071 Employment Status nsPreference for PTSD care ns

31. Health Care Usage ** * *

32. Preference for Care Setting

33. Predictive Significance of Factors Barrier Descriptionp-value I don’t want medication 0.0013 I don’t understand when providers talk about PTSD 0.0054 A problem would have to be very bad 0.0097

34. Predictive Significance of Factors Barrier Descriptionp-value I don’t want medication 0.0013 I don’t understand when providers talk about PTSD 0.0054 A problem would have to be very bad 0.0097 I don’t want group therapy ns I’m uncomfortable talking about problems ns Stigma (family, friends, career) ns Treatment doesn’t work ns

35. Perceived Barriers

36. * * *

37. Model Design Sex Rurality Age Ethnicity/Race* Education* Rank* Marital StatusTotal Time Deployed Demographics Income* Employment Status Non-VA Plan* Worried about Housing Financial Self-Assessment PCL Score* Use VA for any care* Past Utilization for PTSD* Health Factors VA DoD Community Preferences Medication* Group Therapy Stigma Talk Therapy Understanding* Threshold* Barriers

38. Conclusions Factors that relate to PTSD care-seeking are interwoven and complex Factors not significant in the model include: Rurality, sex, expressed preference for care setting Factors VA may influence to increase use of VA for PTSD care: Encourage veterans to use VA for any type of medical care At any VA appointment, encourage trying PTSD care once Focus especially on: Not Retired, Enlisted, Bachelor’s degrees, higher incomes, and high needs (higher service connection)

39. Thank you For information on continuing analysis, or other questions, contact: Erin P. Finley, PhD MPH finleye@uthscsa.edu

40. Obtaining CME/CE Credit If you would like to receive continuing education credit for this activity, please visit: http://amsus.cds.pesgce.com