Trends in Preventative Health Services for Veterans with Military Coverage Compared to Non-Military Coverage
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and Salomeh Keyhani, MD, MPH2,3
1
Division of Nephrology, University of California, San Francisco, CA, USA; 2Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
3
J Gen Intern Med DOI: 10.1007/s11606-019-05377-w © Society of General Internal Medicine 2019
INTRODUCTION
Veterans have a wide range of health care coverage options through military sources, including Veterans Affairs health care and TRICARE health plans, and non-military sources, including private insurance, Medicare, and Medicaid.1 Multiple comparisons have demonstrated that care in VA facilities outperforms care in health care settings; however, differences in care delivery based on coverage source have not been fully evaluated. 2–4 Increasingly, non-military payors have established numerous quality reporting programs and incentives in primary care, which may impact care delivery differentially in veterans with military compared with non-military coverage.5 We examined the quality of preventative care delivery over time among veterans with military coverage compared with non-military coverage.
METHODS
We performed a serial cross-sectional analysis of the Behavioral Risk Factor Surveillance System survey, a federally funded nationally representative telephone survey. Our sample included veterans, and our predictor was TRICARE, VA, or military care, assessed by “What is the primary source of your health care coverage?” We assessed two time periods, 2000 and 2014–2017, as coverage information for Veterans was available for those years in the BRFSS. Our primary outcomes were preventative health services, according to United States Preventative Services Task Force recommendations, the Centers for Disease Control, and American Diabetes Association guidelines. Outcomes were categorized as cancer screening (colorectal cancer, breast cancer, cervical cancer); cardiovascular risk reduction (cholesterol checked in the low-risk and high-risk individuals, aspirin use); infectious disease prevention (influenza vaccination, Received June 19, 2019 Revised July 15, 2019 Accepted September 12, 2019
pneumonia vaccination, HIV testing); and diabetes care (hemoglobin A1c checked, foot examination, eye examination, and influenza vaccination, pneumonia vaccination). We first compared the receipt of preventative health care in veterans with military coverage compared with non-military coverage using chi-squared tests, stratified by time period. We performed multivariable logistic regression to assess the difference in military compared with non-military coverage, adjusting for patient demographics (age, sex, and race) and social factors (employment, education, income, and marital status). We assessed the interaction of military coverage across the two time periods to determine if differences between military and non-military coverage were changing over time.
RESULTS
Survey responses from 67,833 Veterans were included in the analysis, representing 36,029,691 observations
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