Reviewer’s report
Title: 
Reversals in Initially Denied Department of Veterans Affairs’ PTSD
Disability Claims After 17 Years: A Cohort Study of Gender Differences
Version: 
0 
Date: 
28 Nov 2020
Reviewer's report:
Unblinded Review for BMC Women's Health
Author: Murdoch et al.
Title: "Reversals in Initially Denied…"
Reviewer: Brian Shiner
Date: November 28, 2020
OVERALL IMPRESSIONS: 
This is a well-done analysis by a group with a long
history of work in military related disability for PTSD and related areas. 
The
authors perform a longitudinal follow-up study of a group of veterans whose
PTSD disability claims were initially denied in the 1990s (T1). 
Because veterans
may appeal disability decisions, the authors' previously published work assessed
eventual decision status in 2000s (T2). The present study examines service
connection in men versus women in 2016 (T3). 
This study was motivated by a
2011 change in Veterans Benefits Administration (VBA) rules that allowed use
of documented "markers" (changes in behavior that may be associated with
military sexual trauma [MST]), rather than explicit documentation of MST, in
military service records, to link a diagnosis of PTSD to military service. 
In the
present study, the authors found that even after the 2011 rule change, the VBA
disability process continues to favor men with PTSD claims. 
Strengths include a
longitudinal design with survey-based standardized assessment of combat and
sexual trauma at T1, use of a propensity-score based approach for causal
analysis, and assessment of potential unmeasured confounding using the E-
value. 
Weaknesses include a lack assessment in gender-based differences in
appeals submission, relatively weak assessment of gender-based differences in
T2-T3 PTSD status, and evaluation of the 2011 marker rule in an older sample
that was trauma exposed during a period where military service records may be
less copious and searchable than available for post-9/11 veterans, who were not
included. 
Thus, it is unclear whether the gender-based difference in the
longitudinal success rate of initially-denied PTSD disability claims we are
observing a represents a disparity, and the authors are forthright about this in
their interpretation of the relatively small E-value. This work does have a
potential practice implication, in that it may help to make veteran women from
the eras examined more aware of the 2011 marker rule and to improve the
process for these women to submit their appeals. 
While my specific critiques will
follow the BMC "required changes/suggested changes" rubric, I will make all
changes "suggested" as it is absurd for me to require anything of my colleagues.
ABSRACT: The abstract is fine.
"Required Changes:" None
"Suggested Changes:" None
INTRODUCTION: 
This 6-paragraph introduction is generally clear (military
disability, military disability for PTSD, gender differences in MST versus
combat, research gap 1, research gap 2, research gap 3). 
Paragraph 6 (research
gap 3) begins "our third goal." 
Paragraphs 4 and 5 do not similarly state
numbered goals, so this is confusing. 
It would be helpful if the authors could
construct paragraphs 4-6 around specific research gaps to be addressed and
objectives in a parallel manner. 
This would make it easier to evaluate the rest of
the manuscript.
"Required Changes:" None
"Suggested Changes:" Improve paragraphs 4-6 as noted above.
METHOD: 
-Study Design - This is fine.
-Participants - The original 1990s study over-sampled women to achieve gender
balance. 
In the present study, there are over twice as many women as men. 
It
appears this was a function of more women having their initial PTSD claims
denied rather than a new sampling decision, but it might be helpful if it was more
directly stated as it is somewhat remarkable.
-Outcomes - Outcomes include PTSD service connection (SC) status (0/1), any
SC status (0/1), and total SC rating. 
It appears that total rating is treated as a
continuous variable in analyses (e.g., the authors report means later on).
However, my experience with SC is that it is more of a categorical value (e.g.,
none and 0% have different meanings, values are generally assigned in
gradations of 10%, and some thresholds such as 70% mean more than others in
terms of benefits determination). 
Thus, it may have been helpful to have a more
nuanced treatment of the total SC rating, including possible treatment as a
categorical rather than continuous value.
-Main Independent Variable - Dichotomous baseline gender seems fine to me. 
In
my group, we have seen relatively little reassignment of gender status in VA
medical records among those in PTSD treatment during this era (i.e., single
digits), so I agree with leaving it static.
-Potential Confounders/Data Sources - Combat and MST were assessed with
multi-item scales and then dichotomized as 0/1 variables. 
It would be helpful to
have more description of how this performed and why the authors chose this
approach. 
PTSD diagnosis was assessed at time 2. 
As far as I can tell, this was
using one or more ICD-9 code of 309.81 sometime close to T2. 
The authors have
previously argued for a greater degree of sophistication regarding medical-record
based assessment of PTSD status (e.g., Spoont et al., 2010, Psychiatric Services,
PMID: 20044419; Gravely et al. 2011, JRRD, PMID: 21328160), citing factors
such as the clinic where the diagnosis was assigned and the frequency of
diagnostic assignment. 
It would be helpful if the authors would at a minimum
described the window of assessment around T2 and preferentially explained their
choice of a minimal diagnostic rule (e.g., avoiding bias towards heavier VA
service users). 
Furthermore, in clinical practice there seems to be quite a bit of
emphasis on "getting information in the chart" for SC exams. 
This seems at times
to be driven by service officers, clinicians, and veterans themselves. 
Given that
VA records are used by SC examiners both in preparing for exams and in
completing reports that are submitted to the VBA, it would be helpful to know
why the authors did not look at amount of VA service use, especially VA mental
health service use. 
Finally, it seems an omission that the authors did not assess
whether veterans filed additional SC claims or appeals of their initial claims
during the time period examined. 
Another important variable to assess, if
available would have been how long the initial claim was open after initial
denial. 
Though it is clearly not fair, persistence may be related to eventual
success.
-Analysis: 
As alluded to above, use of sufficient summary scores both for data
reduction and covariate balancing is a nice feature of this study, as is the use of
E-value for assessment of unmeasured confounding. 
My only analytic critiques
relate to treatment of variables (total SC rating and T2 PTSD diagnosis), and
exclusion of potentially important variables (amount of VA services use, whether
veterans filed additional claims or appeals) as above.
"Required Changes:" None
"Suggested Changes:" Described above; summary list:
-Please clarify origin of unequal sample size for men versus women in the
current study.
-Please address total SC rating as a continuous versus categorical variable.
-Please address dichotomization of initial MST and combat trauma assessments.
-Please address nuances and potential nuances of T2 PTSD status assessment.
-Please address why VA service use variables were not included.
-Please address why VBA new claims and appeals data were not included.
RESULTS: The figure is cool. 
The tables are generally fine and clear. The one
thing that would be helpful is to state one of the results from the mediation
analysis (Table 3) in plain English in order to make the rest of the table easier to
interpret. 
For example, the current text says "History of military sexual assault
had the largest impact, with a 77% effect modification." 
Does this mean that men
with MST had 77% higher odds of T3 service connection than women with
MST?
"Required Changes:" None
"Suggested Changes:" Please write one of the results from Table 3 in plain
English as a template for interpretation for non-statisticians.
DISCUSSION: 
The discussion is good. 
The authors hit what I think are the most
important limitations, which are 1) the E-value indicates that some relatively
small additional piece of information could nullify this result, and 2) we don't
really know how this would look in post-9/11 Veterans.
"Required Changes:" None
"Suggested Changes:" None
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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Are the methods sufficiently described to allow the study to be repeated?
Yes
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Yes
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Yes
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from apparent manipulation?
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