TY - JOUR
KW - Aged
KW - Cohort Studies
KW - Female
KW - Health Services Accessibility/organization & administration
KW - Humans
KW - Male
KW - Mental Health/statistics & numerical data
KW - Mental Health Services/organization & administration
KW - Middle Aged
KW - Patient Acceptance of Health Care/statistics & numerical data
KW - Primary Health Care/organization & administration
KW - Referral and Consultation/organization & administration
KW - United States
KW - United States Department of Veterans Affairs
KW - Veterans/psychology/statistics & numerical data
AU - L. B. Leung
AU - L. V. Rubenstein
AU - E. P. Post
AU - R. B. Trivedi
AU - A. B. Hamilton
AU - J. Yoon
AU - E. Jaske
AU - E. M. Yano
A1 - 
AB - IMPORTANCE: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
AD - Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles.; Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles.; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles.; RAND Corporation, Santa Monica, California.; Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan.; Department of Medicine, University of Michigan Medical School, Ann Arbor.; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California.; VA Palo Alto Health Care System, Menlo Park, California.; Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.; Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles.; VA Palo Alto Health Care System, Menlo Park, California.; Department of General Internal Medicine, University of California, San Francisco.; VA Puget Sound Health Care System, Seattle, Washington.; Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.; Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles.
BT - JAMA network open
C5 - Financing & Sustainability; Healthcare Disparities
CP - 10
DO - 10.1001/jamanetworkopen.2020.20955
IS - 10
JF - JAMA network open
LA - eng
M1 - Journal Article
N2 - IMPORTANCE: Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE: To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES: Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES: Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS: This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE: While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
PY - 2020
SN - 2574-3805; 2574-3805
T1 - Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans
T2 - JAMA network open
TI - Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans
U1 - Financing & Sustainability; Healthcare Disparities
U2 - 33079197
U3 - 10.1001/jamanetworkopen.2020.20955
VL - 3
VO - 2574-3805; 2574-3805
Y1 - 2020
Y2 - Oct 1
ER -