History has long acknowledged the immediate 

and physical wounds of war. The less visible 

wounds have also been recognized throughout 

history, with each war bringing a unique perspective to the same fundamental problem – an often 

debilitating reaction to the stress of combat. An 

expanding knowledge of the nature of combat 

stress has led to a greater appreciation of the 

range and complexity of both the visible and less 

visible and/or delayed wounds of war. The management of these unique aspects of “deploymentrelated injuries” has been a core responsibility of 

the Veterans Health Administration (VHA) dating back to the Civil War.

VHA has become increasingly focused on 

providing a patient-centered approach to care 

when addressing the short-term needs of the 

newly returning Veteran as well as the longterm needs of an aging Veteran population, 

including the treatment of acute illness and injury and the management of chronic diseases. 

However, all combat-related injuries, both 

physical and psychological, can impact the 

health of the Veteran in unique ways. 

Deployment Health

Deployment health is increasingly recognized as 

a complex constellation of issues that involves 

a variety of physical, mental, and environmental 

exposures. According to the Institute of Medicine, deployment health is defined as health issues 

that arise prior to, during, and following armed 

forces deployments.1 These health issues include 

specific diagnosable conditions, e.g., conditions 

associated with Agent Orange (AO) exposure, 

radiation exposure, prisoner of war status, Gulf 

War associated conditions, and others. Seemingly 

unexplained symptoms, both physical and mental, affect health-related quality of life, can impair 

family and social relationships, and can contribute 

to substance use disorders. These are among the 

more significant sequelae attributed to combat 

injuries. While some of these health challenges 

are immediately apparent when Veterans return 

from deployment, others may not arise until 

much later. 

Mental health conditions once referred to as 

“soldier’s heart,” “shell shock,” “war neurosis,” 

and “combat fatigue” are now better understood 

as discrete illnesses secondary to Post Traumatic 

Stress (PTS). Mental health experts are still not in 

full agreement as to when PTS becomes a disorder, commonly known as Post Traumatic Stress 

Disorder (PTSD). Further, the myriad manifestations of traumatic brain injury (TBI) are better 

recognized, including its late complications. Yet, 

even as new treatment approaches have been put 

in practice and research into disease mechanisms 

and potential treatments has yielded encouraging 

opportunities, there remains much to learn. 

With regard to environmental exposures, the nation became more aware of deployment health 

risks when it was acknowledged that Agent 

Orange was associated with a number of human 

health disorders including cancer, diabetes, and 

heart disease. Veterans’ concerns about exposure 

to pollutants associated with burning trash (and 

oil wells) in the Persian Gulf conflicts have increased interest in both their potential ill-effects 

as well as the appropriate management of waste 

at these sites. Because the health effects of these 

Commentary

Post-Deployment Injuries: A Core 

Responsibility and Challenge

Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary for Health, Washington, D.C. 

 May 2011

Contents

Director’s Letter 2

Co-Occurrence of PostDeployment Health Problems 3

Research Highlight

• Findings from an HSR&D 

Funded Study of TBI 4

Research Highlight

• Pain Management and 

Post-Deployment Care 5

Research Highlight

• Women and Post-Deployment

Health 6

HSR&D National Meeting 

Emphasizes Collaboration 7 

Shekelle Receives 2011 Under 

Secretary’s Award for Outstanding 

Achievement in Health Services 

Research 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

Creation Date: 04/13/10

File Name: VA FORUM 4-2011 Indicia

Modification Date: April 29, 2011 3:40 PM

Ok to Print: 04/29/11

Job Information
practices may come to light years and even decades after the time of exposure, it is extremely 

difficult to develop conclusive epidemiologic 

evidence linking a specific exposure to specific 

disease(s). 

In addition, out-of-U.S. deployments can lead to 

infectious disease exposures rarely encountered 

at home. Despite efforts to inoculate troops 

against endemic agents common at the sites 

of deployment, much is left uncovered. That, 

along with social behaviors of troops deployed 

in foreign lands, can create unique problems for 

a specific cohort of patients not recognized until 

late after demobilization (e.g., hepatitis C in Vietnam Veterans).

Integrated, Patient-Centered Care 

VHA strives to understand and manage the 

secondary contribution that deployment-related 

conditions like TBI, PTSD, and depression have 

on the incidence and progression of chronic 

diseases such as ischemic heart disease, heart 

failure, diabetes, etc. VHA has implemented 

system-wide health screening for all Veterans 

who come to VA for health care services with 

a focus on depression, PTSD, military sexual 

trauma, TBI, risk of suicide, and problem drinking, with the explicit intent to both understand 

and to provide treatment for these conditions 

and their sequelae. In recent years, VHA has 

enhanced its mental health and suicide prevention teams to facilitate mental health care access 

through integration into primary care in order to 

p

Aligned Care Teams (PACT), designed to improve access, care coordination, communication, 

and continuity of care. A principal goal of PACT 

is that Veterans take an active role in their health 

care by utilizing enhanced communications and 

building long-term relationships with their care 

team. VHA has supported the development of a 

number of unique PACT care models, which in 

collaboration with VA researchers, will be evaluated to determine the most effective approaches 

for enhancing Veterans’ care. 

Toward the Future

An improved understanding of Veterans’ health 

care issues, which includes the development of 

new approaches to treatment and the appropriate research tools, is a priority for VHA. These 

tools include registries, cohort management 

studies, and an understanding of the genomic 

contribution to disease. For this reason, the 

Million Veteran Program (MVP), which utilizes 

strict privacy and confidentiality controls, was 

established to provide one of the largest databases of genetic, military exposure, lifestyle, and 

health information. By combining knowledge of 

the human genome with longitudinal data from 

the electronic health care record, researchers will 

have the tools to develop greater understanding 

of disease risk and insight into the fundamental 

etiologies that provide the foundation for new 

potential treatments. This will indeed be a national treasure!

Another example is the active medical surveillance program associated with Veterans 

who served at the Qarmat Ali water treatment facility near Basrah, Iraq, between April 

and November of 2003. Environmental 

health physicians will examine these Veterans 

at regular intervals to determine in particular 

the status of the respiratory system and skin 

– areas known to be affected by exposure to 

hexa-valent chromium. The examination will 

focus on nasal-septal ulcerations and chronic 

irritation; reactive airway disease and other 

Many have complex comorbid medical problems that might 

include traumatic brain injury (TBI), limb amputation, vision and 

hearing loss, chronic pain, as well as mental health and adjustment issues. VA researchers are dedicated to discovering solutions to the multiple health issues that 

result from the unique brutality of modern warfare, such as polytraumatic injuries 

from improvised explosive devices (IEDs). 

In this issue of FORUM, we are honored to have Robert Jesse, M.D., Ph.D., Principal Deputy Under Secretary for Health, discuss VA’s commitment to providing 

optimal post-deployment health care. Part of this includes focusing on patient-centered care, including the development of Patient-Aligned Care Teams (PACT). Dr. 

Jesse also emphasizes the importance of collaborative research, so that clinicians, 

policymakers, and researchers work together to improve the quality of VA care. 

Also in this issue, Nina Sayer, Ph.D., Director of VA/HSR&D’s Polytrauma & BlastRelated Injuries Quality Enhancement Research Initiative (PT/BRI-QUERI), discusses the need to address questions about co-occurring post-deployment health 

problems. For example, how should clinicians prioritize Veterans’ multi-system 

problems? This issue also features articles on women and post-deployment health, 

pain management, and TBI screening. 

HSR&D researchers continue to prioritize deployment-related health care. 

Current areas of investigation include: TBI, mental health (e.g., depression, PTSD), 

rehabilitation, community reintegration, substance use disorders, and issues 

unique to women Veterans. For more information about our research, please go to 

www.hsrd.research.va.gov. 

Seth Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2011

Continued on page 8
VA Office of Research & Development, Health Services Research & Development Service May 2011

Over 2.2 million U.S. service members have 

participated in Operation Iraqi Freedom and 

Operation Enduring Freedom (OEF/OIF), 

about half of whom have left active duty and 

become eligible for VA services. Since 2002, 

the proportion of OEF/OIF Veterans using 

VA has been increasing such that by September 2010, 625,384 (approximately 50 percent) 

OEF/OIF Veterans had obtained health care 

through VA. OEF/OIF Veterans now comprise approximately 7 percent of VA users. 

OEF/OIF VA users are demographically 

distinct from other Veteran cohorts. For 

example, approximately 70 percent are 31 

years old or younger; 12 percent are female; 

and 46 percent deployed to OEF/OIF from 

Reserve/National Guard components of the 

military. Most have access to the Internet 

and use it daily. As Dr. Jesse points out in his 

commentary, OEF/OIF Veterans may also 

have deployment-related health problems, 

many of which are not visible, but which 

VA is uniquely equipped to diagnose and 

treat. These problems include the sequelae of 

psychological and physical trauma in the war 

zone. Furthermore, even in the absence of diagnosable disorders, OEF/OIF Veterans may 

have difficulty adjusting to civilian life after 

combat experiences and these reintegration 

difficulties may have implications for health, 

health behaviors, and outcomes. 

Innovations in Post-Deployment 

Care

VA has implemented significant innovations 

to help ensure that the visible and invisible 

problems of these returning Veterans are identified and treated. Dr. Jesse referred to national 

screening for a range of post-deployment health 

concerns, new patient registries, and suicide prevention. Additional innovations include a system 

of care for Veterans with Traumatic Brain Injury 

(TBI)/polytrauma and, more recently, a separate 

system of care for Veterans with amputation, 

primary care clinics specializing in OEF/OIF 

Veterans’ issues, improved collaboration with 

the DoD to facilitate Veterans’ transition across 

health care systems and to share information, 

and expanded programs for family caregivers, 

particularly but not exclusively for the family caregivers of those with severe war-related 

injuries. These initiatives have also created new 

opportunities for researchers to expand the 

evidence-base for practice and to partner with 

clinicians, VA, and DoD leaders to improve 

post-deployment health care. 

It has been almost ten years since 9/11. Research on post-deployment health in U.S. 

Veterans conducted over the past decade 

spans numerous medical and social science 

domains. One finding across studies stands 

out as warranting particular attention because 

of its implications for health care delivery – 

the co-occurrence of post-deployment health 

concerns in OEF/OIF Veterans. That is, VA 

researchers are not only shedding light on the 

prevalence of specific post-deployment health 

disorders but also on the fact that deployment-related health problems do not occur in 

isolation. In fact, co-morbidity of conditions 

that cut across specialty medical areas is the 

rule rather than the exception. This finding is 

illustrated in the case of Veterans who have a 

history of combat-related TBI. VA researchers are showing that Veterans with probable 

mild TBI usually have Post Traumatic Stress 

Disorder (PTSD) or another mental health 

disorder and pain-related diagnoses.1, 2 We 

also know that dual (auditory and visual) sensory impairment is common in Veterans with 

deployment-related mild TBI.3

The finding of co-occurrence of post-deployment health problems creates challenges for 

health care systems and interventional strategies 

organized around specific conditions or diseases. 

cal practice guidelines typically focus on single 

disorders and therefore may offer less guidance 

than needed (e.g., there are separate clinical practice guidelines for PTSD, mild TBI, and pain). 

How should they be altered to ensure that VA 

garners the evidence it needs and Veterans with 

multi-system comorbidities receive evidencebased care? Dr. Jesse’s commentary brings our 

attention to the PACT care model. How should 

PACT and specialty care teams interact to meet 

the needs of complex OEF/OIF patients who 

may require a range of behavioral as well as 

medical interventions? 

Importance of Collaboration

I was pleased that Dr. Jesse ended his commentary by noting the importance of collaboration 

with researchers. Addressing questions about 

the models of care and treatment protocols for 

OEF/OIF Veterans with multiple deploymentrelated morbidities will require partnership 

among clinicians, policymakers, and researchers. 

In addition, it will be important for researchers 

and policymakers to work together to determine 

whether VA can extend its reach to OEF/OIF 

Veterans who do not yet use VA but could benefit from its expertise in post-deployment health. 

Indeed, VA researchers have an important role 

to play in helping VA achieve its goal of providing this new cohort of Veterans with data-driven, 

patient-centered care. 

References

1. Lew HL, Otis JD, Tun C, et al. Prevalence of Chronic 

Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma 

Clinical Triad. Journal of Rehabilitation Research and Development 2009; 46:697-702.

2. Carlson KF, Nelson D, Orazem R, et al. Psychiatric Diagnoses among Iraq and Afghanistan Veterans Screened 

for Deployment-Related Traumatic Brain Injury. Journal of 

Traumatic Stress 2010; 23:17-24. 

3. Lew HL, Pogoda TK, Baker E, et al. Prevalence of Dual 

Sensory Impairment and Its Association with Traumatic 

Brain Injury and Blast Exposure in OEF/OIF Veterans. 

Journal of Head Trauma Rehabilitation 2011 (e-Published 

ahead of print March 7).

Nina A. Sayer, Ph.D., Polytrauma/Blast-Related Injury QUERI, Minneapolis VA 

Medical Center
Traumatic Brain Injury (TBI) is a leading 

injury among forces deployed since 2001 

to combat areas such as Afghanistan and 

Iraq. Deployed service members are currently eligible for up to five years of health 

care services through the Veterans Health 

Administration (VHA), with no co-payments 

regardless of income or disability. In recent 

years, 20 percent to 25 percent (400,000 or 

more) of these eligible service members have 

used VHA care.1 Therefore, identifying TBI 

among VHA patients is essential, so that 

timely and appropriate treatment can alleviate 

its physical, emotional, and cognitive effects. 

Screening for TBI

To identify patients who may have had TBI, 

VHA policy is to screen all individuals who 

report OEF/OIF deployment, using sets of 

questions about events (e.g., blast, fall, vehicle 

accident) associated with increased risk for 

TBI, immediate symptoms after the event, new 

or worsening symptoms following the event, 

and symptoms in the past week. A screen is 

positive if a person responds positively to any 

question within each set. 

Not all patients who screen positive have 

TBI. Positive screens may be due to other 

conditions, such as PTSD or inner ear injury. Based on its experience with Veterans 

from past conflicts, VHA screening aims to 

be inclusive, referring patients with lower 

probability of having TBI for comprehensive evaluations to ensure that those needing care receive appropriate assessment 

and treatment. Using a defined protocol 

administered by a clinician, the Comprehensive TBI Evaluation collects information about the origin of the injury, assesses 

neurobehavioral symptoms, includes a targeted physical examination and psychiatric 

history, confirms or rules out a diagnosis of 

TBI, and lists possible follow-up care.

Our HSR&D-funded, service-directed research 

study examined the screening, evaluation, 

and utilization records for more than 216,000 

patients seeking VHA services between April 

2007 and March 2009. The proportions with 

positive screens, by gender, were 10.5 percent 

for women (who comprised one eighth of 

the patients) and 21.3 percent for men.2 Approximately 5 percent of women (n = 1,912) 

and 11 percent of men (n = 31,873) who were 

screened for TBI subsequently participated in 

a Comprehensive TBI Evaluation. Of these, 

nearly equivalent proportions of women (34 

percent) and men (37 percent) were confirmed 

to have deployment-related TBI. Of note, blast 

exposure (compared to non-blast events such 

as vehicle accidents) increased the odds of having PTSD, alcohol-related disorders, or PTSD 

with comorbid depression. Blast exposure also 

increased the odds of having severe affective 

(e.g., irritability, frustration) and cognitive (e.g., 

forgetfulness, poor ability to concentrate) neurobehavioral symptoms. 

We found that women with deploymentrelated TBI report more severe postconcussive symptoms, especially if they have 

experienced blast exposure. In terms of 

PTSD, although women had lower odds 

of having a PTSD diagnosis in univariate 

analyses between gender and PTSD (59.6 

percent of the women had a PTSD diagnosis compared to 67.8 percent of the men), 

this difference was not maintained after 

controlling for blast exposure.

Sensory Impairment and TBI

Among those with TBI, self-reported sensory impairment rates were: 34.6 percent 

for dual sensory (both hearing and vision) 

impairment, 31.3 percent for hearing impairments only, 9.9 percent for vision impairments only, and 24.2 percent for none/

mild sensory impairment.3 Patients with 

In the year following screening, the vast 

majority of screened patients received VHA 

health care services (from 88 percent to 98 

percent). Amounts or intensity of services 

were higher for those with TBI and PTSD. 

Women tended to receive more outpatient 

care (about four visits) than men, but men received more inpatient care (about nine more 

days for the approximately 9 percent of men 

and women who received any inpatient care).

Our study found that VHA’s TBI screening 

and evaluation process succeeded in being inclusive, providing follow-up care for service 

members who screened positive for possible 

TBI. Because the study population was large, 

we identified important differences between 

injured men and women in the services as 

well as establishing that those with mild 

deployment-related TBI report high rates of 

dual sensory impairments. The study does 

not generalize to all OEF/OIF-deployed service members, just to those who seek VHA 

health care. Future analyses will examine factors related to variations across VHA medical 

centers regarding specific diagnoses or conditions, types of referrals and follow-up care 

for specific conditions (e.g., PTSD), as well 

as differences by gender, military services 

(e.g., Army, Navy) and the number of events 

(both blasts and non-blasts). 

References

1. Hendricks A, et al. Screening for Mild Traumatic Brain 

Injury in OEF-OIF Deployed Military: An Empirical 

Assessment of the VA Experience. Research paper presented at the February 2011 National HSR&D Conference, Washington, D.C. 

2. Baker E, et al The Differential Pattern of Post-Concussive Symptoms Among Female Compared to Male 

OEF/OIF Veterans with Deployment-Related TBI, 

Plenary presentation at the February 2011 National 

HSR&D Conference, Washington, D.C.

3. Lew HL, Pogoda TK, Baker E, et al. Prevalence of Dual 

Sensory Impairment and Its Association with Traumatic 

Brain Injury and Blast Exposure in OEF/OIF Veterans. 

Journal of Head Trauma Rehabilitation 2011 (e-Published 

ahead of print March 7).

VA Office of Research & Development, Health Services Research & Development Service April 2011

Ann Hendricks, Ph.D., Health Care Financing and Economics, Boston, MA
VA Office of Research & Development, Health Services Research & Development Service May 2011

Emerging data document that painful musculoskeletal and connective tissue disorders 

are the most common cluster of diagnosed 

conditions of Veterans enrolled for care in 

VHA following deployment in Operation Enduring Freedom/Operation Iraqi Freedom/

Operation New Dawn (OEF/OIF/OND). 

At the same time, persistent pain is increasingly appreciated as only one of several highly 

co-prevalent clinically important problems or 

diagnosed disorders among this population of 

Veterans. Data document that a constellation 

of problems including chronic pain, persistent 

post-concussive symptoms, post-traumatic 

stress disorder (PTSD), depressive disorders, 

substance use disorders, and sleep disorders are 

particularly common. Walker and colleagues 

from the James Haley Veterans Hospital – a 

group that has served a particularly important 

role in documenting these comorbidities in 

this population of Veterans – have offered the 

label of “Post-Deployment Multi-Symptom 

Disorder” to best characterize this complex 

array of problems confronting a large proportion of OEF/OIF/OND Veterans.1

 These 

VHA health services investigators have called 

for the development and evaluation of readily 

accessible and Veteran-centered approaches to 

assessment and treatment – novel approaches 

that emphasize interdisciplinary, integrative, 

and coordinated care. 

Role of Patient Aligned Care 

Teams

VHA has established pain management as a 

high priority and has recently published policy 

guidance that calls for implementation of a 

stepped-care approach to pain management.2

The stepped-care model is an evidence-based 

and population-based approach that is consistent with OEF/OIF/OND Veterans’ pain 

management needs and expectations. The 

model calls for most common pain conditions 

to be assessed and managed by interdisciplinary 

Patient Aligned Care Teams (PACTs). For Veterans with complex chronic pain conditions 

that cannot be managed in the PACT setting – 

including those with comorbid mental health 

and medical conditions and those identified as 

at greatest risk for disability, addiction, and suicide – timely access to secondary specialty care is 

required. Pain medicine, rehabilitation medicine, 

mental health and substance use disorders treatment, and specialty medical and surgical services 

are among those that must be readily available to 

support PACTs and Veterans who require this 

level of specialty care. Finally, the stepped model 

calls for building tertiary, interdisciplinary pain 

centers in each VISN by September 2014. These 

centers are expected to have the capacity to 

provide the highest level of advanced pain medicine diagnostics and interventions, chronic pain 

rehabilitation, and treatment for Veterans with 

comorbid complex chronic pain and substance 

use disorders, especially prescription opioid dependence and addiction. 

PACTs are well suited to provide this kind of integrated and coordinated care due to the increasing availability of additional resources that can 

be brought to bear on addressing military-related 

issues and comorbid mental health and substance 

abuse problems. These resources include OEF/

OIF/OND support teams, polytrauma support 

clinical teams, post-deployment clinics and teams, 

and mental health-primary care integration teams. 

Substantial efforts are underway to strengthen 

PACT members’ competencies and to build 

PACT capacity for pain management. Simultaneously, health services investigators in conjunction 

with their service delivery and operations partners 

are developing and evaluating novel approaches 

to delivering efficient chronic pain assessment 

and management in these settings. Among these 

initiatives are those that incorporate the use of 

telehealth and other technological advances to 

promote safe and effective use of medications 

and delivery of non-pharmacological interventions. These include evidence-based psychotherapies, structured exercise and healthy living 

depression and PTSD – and that meet these 

Veterans’ expectations for timely, efficient, and 

effective care – is a high priority.3 

New PACT-Specialty Care Access 

Network

A new VHA initiative called PACT-SCAN 

(Specialty Care Access Network) will soon be 

implemented to further support the development of competencies of PACT teams for the 

assessment and management of chronic pain 

conditions, among other complex chronic 

diseases. The PACT-SCAN initiative will sponsor multidisciplinary specialty teams at regional 

hubs that will use advanced videoconferencing 

technologies to provide didactics and case-based 

learning opportunities for PACTs in rural areas 

and other settings where access to specialty care 

is lacking. A partnership with health services 

investigators is envisioned to provide high fidelity program evaluation that will be necessary 

to assure that the program functions optimally 

to build PACT members’ competencies, to 

improve access to specialized care for Veterans, 

and to promote cost-efficiencies in this mode of 

delivering specialty care.

Meeting the expectations for pain management 

of Veterans returning from deployment in Iraq 

and Afghanistan represents a serious challenge 

to health care providers in VHA and to their 

health services investigator partners. Having 

recognized the challenge, there is reason for optimism that these partnerships will yield important advances in our knowledge about how best 

to assess and manage complex chronic pain and 

to rapidly implement improvements in effective 

Veteran-centered pain care.

References

1. Walker RL, Clark ME, & Sanders SH. The “Postdeployment Multi-Symptom Disorder:” An Emerging Syndrome 

in Need of a New Treatment Paradigm. 

Psychological Services 2010; 7:136-47.

2. Veterans Health Administration. VHA Pain Management 

Directive. Pain Management. Department of Veterans 

Affairs: Washington, D.C. 2009.

3. Otis JD, Keane T, Kerns RD, Monson C, & Scioli E. The 

Development of an Integrated Treatment for Veterans 

with Comorbid Chronic Pain and Posttraumatic Stress 

Disorder. Pain Medicine 2009.10 (7), 1300-11.

Robert D. Kerns, Ph.D., and Alicia Heapy, Ph.D., VA Connecticut Healthcare 

System and Yale University
More than 200,000 women have been deployed 

and, like their male counterparts, experienced 

the high stress of deployment, work, or travel in 

combat areas. While women are not technically 

in combat roles, their duties and service environments can place them at constant risk. Now 

comprising approximately 15 percent of the U.S. 

armed forces overall and 17 percent of Reserve 

and National Guard (R/NG) forces, women 

are among the fastest growing groups of new 

VA users. After a history of caring primarily for 

males and members of the Regular Military, 

VA is now challenged with meeting the health 

care needs of this unique population of women. 

Unfortunately, the health effects of combat, 

post-deployment readjustment, and additive 

trauma exposure (such as sexual assault) are 

not yet well characterized in servicewomen, 

particularly R/NG members. Women Veterans in general report a higher burden of medical illness and worse quality of life outcomes.

Studies of military populations posted at 

permanent bases have had results consistent 

with research on civilian women in finding 

higher rates of depression, anxiety, and posttraumatic stress disorder (PTSD) in servicewomen compared to their male counterparts. 

A potential explanation for this difference 

is that women are significantly more likely 

to experience rape during their lifetime than 

men, and rape is a high risk trauma exposure 

for PTSD and other mental health sequelae.1 

A key concern for returning women Veterans 

is reintegration within family and relationship roles. Little is known about the ways that 

women warriors struggle to balance family and 

service. This is especially important given the 

repeated and prolonged deployments that have 

characterized OEF/OIF/OND service and that 

military women are much more likely to be a 

single parent than male peers. Returning women 

are demonstrating a higher risk for family readjustment problems as marriages of female 

troops are failing at almost three times the rate 

of male service members.2

Facilitating post-deployment access to health 

services, and mental health in particular, for 

OEF/OIF/OND female Veterans is challenging and has required new outreach approaches. 

Such interventions to promote prompt access 

to needed care are urgently needed to mediate 

the severity of post-deployment mental health 

conditions and to interrupt the cycle of chronicity found in many with depression and PTSD.

In focus groups with a Mid-Western cohort of 

R/NG and Regular Military servicewomen (Veteran and active duty), fear of an elevated risk 

of harassment or assault in the VA setting was 

common as were concerns about confidentiality.3

 Participants reported that entry to VA care 

is confusing and that they did not know about 

health care benefits or the availability of genderspecific services.

To attend to access concerns, community 

outreach by VA OEF/OIF/OND teams 

has been implemented to promote education and enrollment of returning Veterans. 

Increasingly, VA is forming partnerships with 

community services and agencies addressing 

Veteran needs (e.g., Brain Injury Association, 

Workforce Development). My HealtheVet 

was developed to respond to changing generational and societal expectations for greater 

electronic access to health care and information. Community-based outpatient clinics 

Services

Once women are VA-enrolled, services and 

the environment and process of care must 

be sensitive to their needs and preferences if 

women Veterans are to continue to choose, 

maintain, and endorse VA care. Gender-specific health services have increased in VA and 

care silos are becoming obsolete as multidisciplinary teams evolve to treat women’s complex health issues and decrease fragmentation 

of care (e.g., Women’s Health Clinics, Patient 

Aligned Care Teams). An unprecedented VA 

implementation of evidence-based practices 

and clinician training to treat trauma and mental health consequences is in process. Recognition of the impact of deployment on family 

reintegration or caretaking roles has resulted 

in the inclusion of licensed marital and family 

therapists within mental health teams and recent family caretaker initiatives.

VA has a research agenda and funding that is 

responsive to the scope, immediacy of health 

concerns, and readjustment problems women 

face post-deployment. The establishment of 

the Women’s Health Research Consortium 

and Practice-Based Research Network is an 

additional VA investment in the growth of 

women’s health research and in the engagement and mentoring of both new and senior 

investigators in women’s health research. 

References

1. Institute of Medicine. Returning Home from Iraq and 

Afghanistan: Preliminary Assessment of Readjustment Needs of 

Veterans, Service Members, and their Families. Washington, 

DC: The National Academies Press 2010.

2. Mulhall, E (2009). Women Warriors: Supporting she who 

has Borne the Battle (Rep. No. October 2009). NY, NY: 

Iraq and Afghan Veterans of America (IAVA).

3. Sadler AG et al. Physical and Sexual Assault in Deployed 

Women: Risk, Outcomes & Services, HSR&D DHI 05-

059; Combat, Sexual Assault, and Post-Traumatic Stress 

in OIF/OEF Military Women, DoD # PTO74819 

&HSR&D # DHI-08136. Iowa City, IA: VA Health 

Care System.

4. Ibid.

VA Office of Research & Development, Health Services Research & Development Service May 2011

Anne G. Sadler, Ph.D., R.N., Center for Comprehensive Access and Delivery 

Research and Education, Iowa City VA Health Care System, Iowa City, Iowa

“You can’t just come back home 

expecting everything to be the way 

it was before, because one, your 

family is not the same. You are 

not the same.” 

Chicago Enlisted Servicewoman4
VA Office of Research & Development, Health Services Research & Development Service May 2011

ary. This year’s theme emphasized HSR&D’s 

priority to establish and maintain close collaborative relationships with its VA partners, 

so that research is more responsive and the 

findings are more likely to be implemented 

into practice. The meeting brought together 

policymakers, clinicians, and researchers, enabling participants to gain exposure to each 

other’s work, to understand each other’s 

needs, and to develop collaborative relationships that will ultimately enhance the health 

care provided to Veterans.

Partners in Research 

More than 650 attendees had access to 90 

papers, 21 workshops, and 113 posters on 

vital health care issues, such as: chronic 

disease management, mental health, substance use disorders, homelessness among 

Veterans, women Veterans’ health care 

Initiative (QUERI). Many of these studies 

depend upon partnerships between HSR&D 

and other VA programs and offices, such 

as the Office of Quality and Performance, 

Patient Care Services, and the Office of Information & Technology. 

National Meeting Highlights

Meeting highlights included a keynote address by VA’s Principal Deputy Under Secretary for Health, Robert Jesse, M.D., Ph.D. 

The title of his talk was “Transactional 

Quality” and he spoke about the importance of differentiating between “delivering 

health care,” which is what VA provides to 

patients, and “health care delivery,” which 

pertains to the systems that enable this care. 

Other meeting highlights included the presentation of awards. Paul Shekelle, M.D., 

Ph.D., M.P.H., received the Under Secre

Doctoral Poster Award to Lauren Broyles, 

Ph.D., R.N., of HSR&D’s Center for Health 

Equity Research & Promotion, for her study 

on alcohol screening. 

Looking Toward the Future

Dr. Eisen addressed meeting participants 

about the future and HSR&D’s priorities, 

which include: engaging VHA partners in 

health services research; further aligning 

investigators with the needs of VA; increasing research synergy and reducing scientific 

overlap; speeding implementation of research findings; and maintaining investigator-initiated research. 

The National Meeting was hosted by HSR&D’s 

Northwest Center for Outcomes Research in 

Older Adults, located in Seattle, WA.

Paul G. Shekelle, M.D., 

Ph.D., M.P.H., has received 

this year’s Under Secretary’s 

award for Outstanding 

Achievement in Health 

Services Research. The 

award recognizes a VA 

researcher whose work 

has met three key criteria: improved our 

understanding of factors that affect the health 

of Veterans and improved the quality of their 

care, contributed to the future of VA health 

services research by inspiring and training the 

next generation of investigators, and enhanced 

the visibility of VA research through national 

recognition within the research community. 

Significant research contributions made by 

Dr. Shekelle include developing methods to 

assess quality of care, particularly for older 

adults. For example, five quality indicators 

he developed are part of VA’s benchmarking 

sets. Through his work at VA’s Health 

Services Research and Development Service 

(HSR&D) Evidence Synthesis Program, 

he has added to the overall knowledge 

regarding how to synthesize evidence in 

order to reach clinically relevant conclusions 

by conducting several evidence syntheses 

targeted toward VA clinical managers. 

Dr. Shekelle has been an important part of the 

VA Greater Los Angeles (GLA) Healthcare 

System for more than 20 years, where he is 

Chief of General Internal Medicine. He also 

leads the HSR&D Evidence Synthesis Program 

based at GLA, is Director of the Southern 

California Evidence-based Practice Center, 

and is Director of the Quality Assessment and 

Improvement Program at RAND.

Joel Kupersmith, M.D., VA’s Chief Research 

and Development Officer, presented Dr. 

Shekelle with the highest honor for a VA 

health services researcher at the HSR&D 

National Meeting in February.

Shekelle Receives 2011 Under Secretary’s Award for 

Outstanding Achievement in Health Services Research
Peter L. Almenoff, M.D., FCCP, 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

Skye McDougall, Ph.D.

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Director, VA 

Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

.

Post-Deployment Injuries from page 2

lung abnormalities; skin ulcerations or 

chronic dermatitis. It will also look for and 

catalog other health conditions that occur 

in this well-defined cohort over time in 

order to identify any potential late complications from this exposure that might not 

yet be appreciated. 

Hand in hand with these new approaches 

and tools is collaboration with researchers 

to understand and develop new approaches 

to improve care for Veterans. This collaboration occurs through a broad spectrum 

from basic to applied research as well as 

population health and implementation sciences. VHA’s development and sustained 

focus on deployment health – a focus that 

engages the Nation’s best investigators 

on the cutting-edge of research – enables 

VHA to provide the highest quality care 

for Veterans. This remains a key priority 

for the Department.

Endnotes

1. Hernandez LM, Liverman CT, and Greenlick MR, 

Editors. National Center for Military Deployment 

Health Research.National Academy Press: 

Washington, D.C. 1999.