MIL12009 814..822

Objective: In order to understand access to treatment services for post-traumatic stress disorder (PTSD) in the Veterans Health Administration (VHA), we reviewed existing literature to estimate the proportion of Iraq and Afghanistan veterans who have used VHA services. Methods: We reviewed studies regarding the prevalence of PTSD among Iraq and Afghanistan War veterans to estimate the need for treatment. We then compared need to Veterans Affairs utilization in order to estimate the proportion accessing care. Results: Access to VHA services is high, with 58% of the estimated population of Iraq and Afghanistan veterans accessing some PTSD-related service. However, there is insufficient information about the quality of these services. Conclusions: The Veterans Affairs has been successful in providing access to treatment services for Iraq and Afghanistan Veterans with PTSD. Additional studies are needed to further characterize the quality of services provided. INTRODUCTION Public policy concerns regarding veterans returning from the Wars in Iraq and Afghanistan with post-traumatic stress disorder (PTSD) are high. Identifying these veterans early and helping them to access evidence-based treatments in a timely fashion may prevent the long-term problems that untreated veterans have experienced. Addressing these policy issues will require, as first steps, estimating the number of returning veterans with PTSD and the proportion who are already accessing services. These estimates are necessary for the Veterans Health Administration (VHA) to address the problems of lack of treatment and inadequate treatment. This article reviews and synthesizes the existing literature on access to derive best estimates. Access is a complex construct. Anderson et al described four aspects—potential access, realized access, equitable access, and inequitable access—based on availability of treatment, use of treatment, and sociodemographic predictors of use. He later delineated the concepts of effective access and efficient access to indicate whether use of health services actually improved health and whether a gradient existed between use and benefit. Thornicroft and Tansella offered two concepts relating need to resources: “true prevalence,” denoting the number of cases of a particular condition, and “treated prevalence,” denoting the fraction of that number receiving care. These concepts, in turn, led to notions of “coverage” as an indicator of the proportion of people who could benefit from a treatment and “focus” as an indicator of whether those people who received a treatment actually needed it. Furthermore, high-quality health care should be easily attainable in terms of geography, payment, waiting time, and cultural relevance. American veterans who have served in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) have been called OEF/OIF veterans. Although American service members continue to serve in other conflicts around the world, their numbers are small, and we have the best data to make estimates of access in the OEF/OIF population. The VHA Environmental Epidemiology Service reported that as of the end of the 2010 fiscal year, over 2.1 million service members served in OEF and OIF, and 1,250,663 had separated from the military and became eligible for VHA services (Internal Report, reviewed below). METHOD Our goal was to estimate the percentage of returning veterans with PTSD who are accessing VHA health care, based on the concept of coverage (the proportion of patients that could benefit and actually receives the service). We therefore sought to summarize available information in order to estimate access in the following equation: Access = Utilization/ Need (Fig. 1). Because the diagnosis of PTSD requires “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” we assumed that every veteran with PTSD has some related health need (our denominator). To estimate PTSD treatment-related needs, we followed a 2-step process. First, we reviewed relevant literature on the prevalence of PTSD among veterans in order to determine the best estimate. Authors from the RAND Corporation of a recent review searched the Published International Literature on Traumatic Stress (PILOTS) database using the terms “PTSD” and “Iraq War or Afghanistan, or Operation Enduring Freedom or OEF” and “epidemiology or health care *VA Medical Center, 215 Main Street, 11Q, White River Junction, VT 05009. †Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1, Lebanon, NH 03766. ‡VA National Center for Patient Safety Field Office, 215 North Main Street, 10A4B1, White River Junction, VT 05009. §VA Northeast Program Evaluation Center, 950 Campbell Avenue, West Haven, CT 06516. kVA National Center for PTSD Executive Division, 215 North Main Street, White River Junction, VT 05009. MILITARY MEDICINE, Vol. 177, July 2012 814 D ow naded rom http/academ ic.p.com /m ilm ed/article-ab/177/7/814/4283715 by gest on 15 M arch 2020 utilization. ” After additional reference and internet searches, the authors identified 29 studies of the prevalence of PTSD among OEF/OIF veterans as of mid-2009. Estimates of PTSD prevalence varied widely between 1.4% and 60%, creating a puzzle for epidemiologic logic. We proceeded as follows. Because treatment-seeking samples are likely to overestimate population prevalence, we eliminated 10 studies that examined treatment-seeking veterans. We also eliminated 11 studies that used convenience samples and one study of British veterans. The seven remaining studies (Tables I and II) included three evaluations of administrative data derived from population-level screening and four population-based surveys. Repeating the original RAND search and applying these additional limitations, we did not find additional studies as of December 31, 2010. Our second step in estimating need was multiplying our expected prevalence of PTSD by the number of VHA-eligible OEF/OIF veterans. For this step, we used data from the FIGURE 1. Access to VHA PTSD services among returning veterans. TABLE I. PTSD Prevalence Estimates Based Upon Population Level Screening Study Sensitive Criteria Specific Criteria Hoge et al, 2006 OEF/OIFPDHA PC-PTSD-2 (Sensitivity 0.91, Specificity 0.72) PC-PTSD-3 (Sensitivity 0.84, Specificity 0.90) 22,584/238,938 10,964/238,938