Differences in cause of death of Washington State veterans who did and did not use Department of Veterans Affairs healthcare services.

INTRODUCTION Relatively little is known about the cause of death in the general veteran population, although more is known about the cause of death in Vietnam and Persian Gulf war veterans [1-3]. Veterans who received specialty mental health services died younger and were more likely to die from infectious diseases, accidents, or suicide than their counterparts who received general medical care only [4]. These findings are consistent with results from the civilian population [5]. Strong evidence exists that veterans who use Department of Veterans Affairs (VA) healthcare services are sicker than veterans who do not [6]. Whether age and cause of death differ among veterans who do and do not use VA healthcare services is unknown. We hope that this article will provide new information about cause of death in a large veteran population. Our first objective was to identify veterans who died in Washington State between 1998 and 2002 and determine whether they used VA healthcare services. Our second objective was to compare characteristics and causes of death according to VA healthcare use in the 5 years prior to death. We were particularly interested in whether the proportion of alcohol--and/or drug-induced deaths differed between users and nonusers of VA healthcare services. METHODS Population We identified deceased veterans through Washington State death certificates, which include a question as to whether the decedent was ever in the Armed Forces of the United States. In this article, we include 62,080 Washington State veterans who died between 1998 and 2002. These veterans were identified from electronic death certificates provided by the Washington State Department of Health. An additional 1,462 veterans with missing or invalid Social Security numbers were not included because we needed the Social Security number to link to VA healthcare use files to identify users of VA healthcare services. Study Variables In addition to date of death and veteran status, we obtained from the death certificate each veteran's age, sex, race, education, marital status, and smoker status during the 15 years before death. The distances between each veteran's residence and the closest VA medical center (VAMC) and outpatient clinic were obtained from VA data sources. The underlying cause of death was also collected and reported using International Classification of Diseases (ICD)-9 codes for veteran deaths in 1998 and ICD-10 codes for deaths in 1999 to 2002. The ICD-9 and ICD-10 codes that we used to define the leading causes of death and alcohol--and/or drug-induced causes are shown in Appendix 1 and Appendix 2, respectively (available online only at http://www.rehab.research.va.gov/). We obtained information concerning use of VA healthcare services 5 years prior to death by linking the Social Security number recorded on the death certificate with a similar number contained in the VA Austin Automation Center files. A scrambled identifier, which was obtained from the linkage, was then used to extract healthcare use information from the relevant Austin Automation Center files. Types of healthcare use included (1) outpatient, (2) acute hospital, (3) extended or nursing home, (4) observation, and (5) authorized non-VA acute hospital. Statistical Methods Analyses were performed separately for female and male veterans. To compare baseline characteristics of users and nonusers of VA healthcare services, we used the chi-square statistic for categorical variables and the two sample t-test for continuous variables. To examine the association between alcohol--and/or drug-induced deaths and use of VA healthcare services, we used the chi-square statistic. We also used logistic regression to determine the association between these two factors after adjusting for demographic and smoking variables. RESULTS Overall, 2,618 female veterans (4% of sample) and 59,462 male veterans were studied; 12 percent of the females and 21 percent of the males used VA healthcare services in the 5 years prior to death. …