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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.104299
RESEARCH AND PRACTICE |
Drew A. Helmer is with the War-Related Illness and Injury Study Center and the Center for Healthcare Knowledge Management, Veterans Affairs New Jersey HealthCare System, East Orange, and the New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark. Mindy E. Flanagan and Bradley N. Doebbeling are with the Center for Implementing Evidence-Based Practice, Richard L. Roudebush VA Medical Center, Indianapolis, Ind, and the Center for Health Services and Outcomes Research, Regenstrief Institute, Indiana University, Indianapolis. Bradley N. Doebbeling is also with the Department of Medicine, Indiana University, Indianapolis. Robert F. Woolson is with the Department of Biostatistics, Bioinformatics and Epidemiology, College of Medicine, Medical University of South Carolina, Charleston.
Correspondence: Requests for reprints should be sent to Bradley N. Doebbeling, MD, MSc, VA HSR&D Center for Implementing Evidence-Based Practice, Roudebush VAMC, 1481 W 10th St (11-H), Indianapolis, IN 46202 (e-mail: bdoebbel{at}iupui.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We sought to analyze the self-reported hospitalization, emergency department visits, and outpatient visits of Persian Gulf War (deployed; n=1896) and Persian Gulf War–era (nondeployed; n=1799) military personnel 5 years postconflict to determine whether these groups had different rates of health care use. Compared with personnel who had not been deployed, personnel who had been deployed were more likely to have visited an emergency department (25% vs 21%; odds ratio [OR]=1.24; 95% confidence interval [CI] = 1.06, 1.51]). Among these groups, the National Guard and Reserve personnel were more likely to have been hospitalized than were the regular military personnel (OR= 1.65; 95% CI=1.21, 2.26).
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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After deployment, many Persian Gulf War personnel reported a variety of symptoms, such as bodily pain, difficulty thinking, feeling depressed, and other complaints.1–3 Theoretically, given their symptoms, these veterans should have higher health care use than non-deployed Persian Gulf War–era veterans.4,5 Little evidence exists for increased hospitalization rates6,7 or outpatient care among Persian Gulf War veterans,8,9 but most studies have not accounted for systematic differences in health status and access to services in this population. It may be that military personnel who remain on active duty are healthier than those who separate. Furthermore, active duty personnel have TriCare health coverage,10 whereas those who separate or are in the National Guard or Reserve rely on other arrangements, which may affect their rates of health care utilization.
We compared emergency department visits, hospitalizations, and outpatient visits among Persian Gulf War veterans and Persian Gulf War–era (nondeployed) veterans 5 years postconflict.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Military personnel from Iowa on active duty August 1990 to July 1991 (N = 29 010) were categorized as Persian Gulf War veterans (those deployed to the Persian Gulf) or Persian Gulf War–era veterans (those not deployed to the Persian Gulf). Independent samples from each of 64 strata based on component (regular military vs National Guard and Reserve), Persian Gulf War deployment, age, gender, race, rank, and service branch were selected (n = 4886).1,11 Participants included 1896 Persian Gulf War veterans and 1799 Persian Gulf War–era veterans.
We used telephone interviews (September 1995–May 1996) to assess individuals for insurance status, alcohol use disorder, anxiety disorder, cancer, chronic fatigue, cognitive dysfunction, depression, chronic pain, injury, multiple chemical sensitivity, posttraumatic stress disorder, respiratory condition, and sexual dysfunction. We used the Short Form–36 to assess health status.12,13 Further details are reported elsewhere.1,11
Health care use variables included number of outpatient visits, emergency department visits, and inpatient stays in the past year.14 Emergency department visits and inpatient stays were dichotomized at 0 versus 1 or more. Outpatient visits were dichotomized (
5 or > 5 visits) for regression models. We used logistic regression models to examine associations between deployment and utilization control for confounders.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Participation was comparable across strata. Compared with Persian Gulf War–era veterans, Persian Gulf War veterans were more often younger, male, enlisted, less educated, and more likely to serve in the US Army or Marines. Fewer Persian Gulf War veterans (21% vs 24%; P = .04) remained on active duty in the year before the survey than did Persian Gulf War–era veterans. When we compared health care use between Persian Gulf War and Persian Gulf War–era veterans, only emergency department visits were associated with Persian Gulf War deployment (Table 1
).
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National Guard and Reserve Persian Gulf War and Persian Gulf War–era personnel were more likely to be hospitalized than were the regular personnel after we controlled for smoking status, insurance coverage, and deployment status, but no other differences in health care use were associated with military component or duty status (Table 2
, model 1). Persian Gulf War veterans remained more likely to make an emergency department visit than did Persian Gulf War–era veterans after adjustment. When the 12 health problems assessed during the telephone interview were added to the previous model, National Guard and Reserve personnel remained more likely to be hospitalized compared with regular personnel, but Persian Gulf War veterans were no longer more likely than were Persian Gulf War—veterans to visit the emergency department (Table 2, model 2).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Five years postconflict, Persian Gulf War veterans were more likely to visit the emergency department but were no more likely than were Persian Gulf War–era veterans to have an inpatient stay or outpatient visit. The findings do not support our hypothesis that Persian Gulf War veterans, who reported more chronic symptoms, would be more likely to make outpatient visits compared with Persian Gulf War–era veterans.
We suggest 2 explanations for the findings. First, the higher probability of emergency department visits by Persian Gulf War veterans could have resulted from limited access to outpatient services, as seen in other populations.15 Alternatively, veterans could have had higher rates of accidents and injuries. Others have documented higher rates of trauma among combat veterans.7,16 Both hypotheses are supported by the attenuation of the association when the health problems, including alcohol use disorder and injury, were added to the model.
The lack of association between hospitalization and outpatient visits with deployment to the Persian Gulf War appears consistent with the absence of serious conditions requiring intensive inpatient or outpatient care. Similarly, the higher odds of hospitalization among National Guard and Reserve personnel may be a result of their relatively older age and the related risk of hospitalization for unmeasured chronic health conditions (e.g., unstable angina). Limited health care access also may have contributed to this association.
We tested a hypothesis based on a theory4,5 that incorporates health care need and access. Participants included those separated from and those remaining in military service in all branches and components. The data were high quality, and the outcome measures were well accepted. Limitations included a reliance on self-report, the incomplete capture of health conditions, and the single state population. However, the consistency of our findings with those of other studies suggests that our results are both valid and generalizable.6–8,17
In conclusion, access to outpatient services may be limited for Persian Gulf War veterans and National Guard and Reserve personnel, perhaps because of health care coverage policies of the Department of Defense and the Department of Veterans Affairs.10 Since 2002, the Department of Veterans Affairs has granted veterans of Operations Iraqi Freedom and Enduring Freedom 2 years of presumptive coverage for deployment-related health concerns.18 Our findings suggest the need to investigate whether this policy change has affected health outcomes or health care use for this population.
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Acknowledgments |
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This work was partially supported by Centers for Disease Control and Prevention (cooperative agreement U50/CCU711513) and the Department of Defense (grant DAMD17-97-1). D. A. Helmer’s work on this project was supported by a Veterans Affairs Health Services Research and Development Research Career Development Award.
The authors sincerely appreciate the contributions of Martha Jones in coordinating the original survey; Teri Snyders for administrative support, particularly in participant location and recruitment; Margaret Voelker in project management; Willliam R. Clarke in overseeing the statistical analyses; David Schwartz in the planning and conduct of the original study; Iowa State University’s Stat Lab personnel in administering the telephone interview and data collection; and members of the Iowa Persian Gulf Study Group in advice in the development and performance of the original telephone survey. The contributions of the Scientific Advisory Committee and Public Advisory Committee in providing advice, input, and review in the development of the project are greatly appreciated. We appreciate methodological input into the analyses from James Rohrer and James Torner. Finally, we appreciate the participation by and support from the military personnel who made this research possible.
Human Participant Protection
All instruments and procedures were approved by the University of Iowa institutional review board. A Public Health Service Certificate of Confidentiality was obtained to protect confidentiality and promote a high participation rate.
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Footnotes |
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Peer Reviewed
Note. The views expressed in this brief are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or other affiliated institutions.
Contributors
D. A. Helmer, M. E. Flanagan, and R. F. Woolson participated in study design, analysis, synthesis, and writing of the brief. B. N. Doebbeling originated, obtained funding for, and participated in all aspects of this study. In addition, M. E. Flanagan managed the data.
Accepted for publication June 7, 2007.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Schwartz DA, Doebbeling BN, Merchant JA, et al. Self-reported illness and health status among Gulf War veterans: a population-based study. The Iowa Persian Gulf Study Group. JAMA. 1997;277:238–245.
2. Fukuda K, Nisenbaum R, Stewart G, et al. Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA. 1998;280:981–988.
3. Eisen SA, Kang HK, Murphy FM, et al. Gulf War veterans’ health: medical evaluation of a US cohort. Ann Intern Med. 2005;142:881–890.
4. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36:1–10.[CrossRef][Web of Science][Medline]
5. Engel CC, Jaffer A, Adkins J, Riddle JR, Gibson R. Can we prevent a second "Gulf War syndrome"? Population-based healthcare for chronic idiopathic pain and fatigue after war. Adv Psychosom Med. 2004;25:102–122.[Medline]
6. Gray GC, Coate BD, Anderson CM, et al. The postwar hospitalization experience of US veterans of the Persian Gulf War. N Engl J Med. 1996;335:1505–1513.
7. Gray GC, Smith TC, Kang HK, Knoke JD. Are Gulf War veterans suffering war-related illnesses? Federal and civilian hospitalizations examined, June 1991 to December 1994. Am J Epidemiol. 2000;151:63–71.
8. Kang HK, Mahan CM, Lee KY, Magee CA, Murphy FM. Illnesses among United States veterans of the Gulf War: a population-based survey of 30,000 veterans. J Occup Environ Med. 2000;42:491–501.[Web of Science][Medline]
9. Gray GC, Gackstetter GD, Kang HK, Graham JT, Scott KC. After more than 10 years of Gulf War veteran medical evaluations, what have we learned? Am J Prev Med. 2004;26:443–452.[CrossRef][Web of Science][Medline]
10. Shelton HH. The military healthcare system. Mil Med. 2001;166:739–740.[Medline]
11. Doebbeling BN, Jones MF, Hall DB, et al. Methodologic issues in a population-based health survey of Gulf War veterans. J Clin Epidemiol. 2002;55:477–487.[CrossRef][Web of Science][Medline]
12. Ware J. Appendix C: Script for Personal Interview SF-36 Administration. Boston, Mass: Nimrod Press; 1993.
13. Voelker MD, Saag KG, Schwartz DA, et al. Health-related quality of life in Gulf War era military personnel. Am J Epidemiol. 2002;155:899–907.
14. Chyba MM, Washington LR. Questionnaires from the National Health Interview Survey, 1985–89. Vital Health Stat 1. 1993;No. 31:1–412.
15. Padgett DK, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Soc Sci Med. 1992;35:1189–1197.[CrossRef][Web of Science][Medline]
16. Bell NS, Amoroso PJ, Wegman DH, Senier L. Proposed explanations for excess injury among veterans of the Persian Gulf War and a call for greater attention from policymakers and researchers. Inj Prev. 2001;7:4–9.
17. Gray GC, Reed RJ, Kaiser KS, Smith TC, Gastanaga VM. Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. Am J Epidemiol. 2002;155:1033–1044.
18. Veterans Health Administration. VHA Directive 2002–049: Combat Veterans Are Eligible for Medical Services for 2-Years After Separation From Military Service Notwithstanding Lack of Evidence for Service Connection. Washington, DC: Department of Veterans Affairs; September 11, 2002.
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