Misconduct-Related Discharge from Active Duty Military Service: An Examination of Precipitating Factors and Post-Deployment Health Outcomes

U.S. military service members who are discharged from service for misconduct are at high risk for mental health and substance use disorders, homelessness, mortality, and incarceration. The purpose of this dissertation was to investigate the pre- and post-discharge experiences and characteristics of this highly vulnerable population in order to inform improved prevention and intervention strategies. Administrative data from the Department of Defense and Veterans Health Administration for veterans of recent conflicts were used to conduct 3 related retrospective cohort studies. These included (1) an evaluation of the demographic and military service characteristics and service-connected disabilities associated with discharge for misconduct; (2) an examination of post-discharge health status and healthcare utilization among misconduct-discharged veterans; and (3) the development of predictive models for homelessness and mortality among misconduct-discharged veterans. Several demographic and military service characteristics were associated with increased risk for misconduct discharge, as were exposure to sexual trauma, and post-discharge designation of service-connected disabilities related to mental illness. Misconduct-discharged veterans were found to have significant and complex healthcare needs, and used clinical services at approximately double the rate of routinely discharged veterans. Several risk factors for homelessness and mortality among this population were identified. Risk stratification models showed good predictive accuracy for homelessness, and fair predictive accuracy for mortality. Targeted counter-attrition strategies and an increased focus on health-related determinants of misconduct, including rehabilitative approaches to behavioral problems, may help to reduce misconduct-related attrition. Efforts to transition post-discharge care from specialty settings to integrated primary care settings may be successful in mitigating adverse outcomes. Risk stratification techniques can facilitate the efficient targeting of resources

Needles in a haystack: screening and healthcare system evidence for homelessness

Effectiveness of screening for homelessness in a large healthcare system was evaluated in terms of successfully referring and connecting patients with appropriate prevention or intervention services. Screening and healthcare services data from nearly 6 million U.S. military veterans were analyzed. Veterans either screened positive for current or risk of housing instability, or negative for both. Current living situation was used to validate results of screening. Administrative evidence for homelessness-related services was significantly higher among positive-screen veterans who accepted a referral for services compared to those who declined. Screening for current or risk of homelessness led to earlier identification, which led to earlier and more extensive service engagement

Comparing the utilization and cost of health services between veterans experiencing brief and ongoing episodes of housing instability

Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.This study was supported by funding from the Department of Veterans Affairs (VA) Health Services Research & Development (HSR&D) grant IIR 13-334-3 and from the VA National Center on Homelessness Among Veterans

Rurality or distance to care and the risk of homelessness among Afghanistan and Iraq veterans

INTRODUCTION: To date, no studies have examined the relationship of rurality and distance to nearest VA facility to risk of homelessness. METHODS: We examined differences in the rate of homelessness within a year of a Veteran's first encounter with the VA following last military separation based on rurality and distance to the nearest VA facility using multivariable log-binomial regressions. RESULTS: In our cohort of 708,120 Veterans, 73% were determined to have a forwarding address in urban areas, 59.2% and 86.7% lived within 40 miles of the nearest VA medical center (VAMC), respectively. Veterans living in a rural area and those living between 20+ miles away from the nearest VAMC were at a lower risk for homelessness. CONCLUSIONS: Our unique dataset allowed us to explore the relationship between geography and homelessness. These results are important to policy makers in understanding the risk factors for homelessness among Veterans and planning interventions

Comparison of Skin Biomechanics and Skin Color in Puerto Rican and Non-Puerto Rican Women

Objective: Skin biomechanics are physical properties that protect the body from injury. Little is known about differences in skin biomechanics in racial/ethnic groups and the role of skin color in these differences. The purpose of this study was to determine the relationship between skin biomechanics (viscoelasticity, hydration) and skin color, when controlling for demographic and health-related variables in a sample of Puerto Rican and non-Puerto Rican women. Methods: We performed a secondary analysis of data from 545 women in a longitudinal, observational study of skin injury in Puerto Rico and the United States. Data included measures of skin viscoelasticity, skin hydration, skin color, demographic, and health-related variables. Skin color was measured by spectrophotometry (L* - lightness/darkness, a*- redness/greenness, b* - yellowness/blueness). The sample was 12.5% Puerto Rican, 27.3% non-Puerto Rican Latina, 28.8% Black, 28.6% White, and 2.8% Other. Results: Regression analyses showed that: 1) higher levels of skin viscoelasticity were associated with lower age, higher BMI, and identifying as non-Puerto Rican Latina as compared to Puerto Rican; (all p \u3c .001); and 2) higher levels of hydration were associated with lower L* values, higher health status, lower BMI, and identifying as non-Puerto Rican Latina, White, or Other as compared to Puerto Rican (all p \u3c .05). Conclusion: When adjusting for skin color, Puerto Rican women had lower viscoelasticity and hydration as compared to other groups. Puerto Rican women may be at long-term risk for skin alterations, including pressure injury, as they age or become chronically ill

Chronic Health Conditions Among US Veterans Discharged From Military Service for Misconduct

Veterans who are discharged from military service due to misconduct are vulnerable to negative health-related outcomes, including homelessness, incarceration, and suicide. We used national data from the Veterans Health Administration for 218,608 veterans of conflicts in Iraq and Afghanistan that took place after the events of September 11, 2001, to compare clinical diagnoses between routinely-discharged (n = 203,174) and misconduct-discharged (n = 15,433) veterans. Misconduct-discharged veterans had significantly higher risk for all mental health conditions (adjusted odds ratio [AOR] range, 2.5–8.0) and several behaviorally linked chronic health conditions (AOR range, 1.2–5.9). Misconduct-discharged veterans have serious and complex health care needs; prevention efforts should focus on behavioral risk factors to prevent the development and exacerbation of chronic health conditions among this vulnerable population

Homelessness and eating disorders among a sample of OEF/OIF recently returned U.S. veterans

Introduction: An estimated 11-14% of the homeless population in the U.S. is comprised of veterans. While the majority of homeless veterans have a mental health diagnosis, eating disorders (ED) remain understudied within this population. EDs are rare among veterans, however, understanding the association between homelessness and ED, while accounting for psychological covariates, could better inform our understanding of the unique mental health care needs of these veterans. Methods: Retrospective data on 265,806 Veterans from the Veterans Health Administration (VHA) were used in this study. Veterans were included in the sample if they had clinical follow-up data for at least five years after their first VA encounter. Logistic regression analysis was used to compute adjusted odds ratios (AOR) for ED as a function of homelessness, controlling for clinical and demographic covariates. Results: Of veterans seeking care at the VHA, 11,876 (4.5%) had evidence of homelessness. A documented diagnosis of ED was observed in 71 (0.6%) of these homeless veterans. EDs were three times more likely among veterans experiencing homelessness as compared to domiciled veterans (AOR=3.55, 95% confidence interval = 2.74-4.53), after accounting for demographic covariates. When controlling for both demographics and mental health comorbidities, ED was more than 50% more likely among veterans experiencing homelessness as compared to domiciled veterans (AOR=1.52, 95% Confidence interval=1.16-2.00; p Discussion: Homeless veterans are at heightened risk for ED. As EDs are potentially fatal, our results reveal that further research is necessary to identify who among homeless veterans are at higher risk for ED. Determination of these risk factors may inform targeted screening strategies among homeless veterans

Association between diseases of despair and atherosclerotic cardiovascular disease among insured adults in the USA: a retrospective cohort study from 2017 to 2021

Objectives To assess associations between diseases of despair (DoD) and incident atherosclerotic cardiovascular disease (ASCVD) among insured adults in the USA.Design Retrospective cohort study.Setting Highmark insurance claims data in the USA from 2017 to 2021.Participants Adults with at least 10 months of continuous insurance enrolment, no record of ASCVD in the 2016 baseline year and no missing data on study variables.Primary and secondary outcome measures Cox proportional hazard regression was used to calculate crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess risk of ASCVD (composite of ischaemic cardiomyopathy, non-fatal ischaemic stroke, peripheral arterial disease or non-fatal acute myocardial infarction) by baseline DoD overall, and by the component conditions comprising DoD (alcohol-related disorders, substance-related disorders, suicidality) individually and in combination.Results The DoD-exposed group had an age-adjusted rate of 20.5 ASCVD events per 1000 person-years, compared with 11.7 among the unexposed. In adjusted models, overall DoD was associated with increased risk of incident ASCVD (HR 1.42, 95% CI 1.36 to 1.47). Individually and in combination, component conditions of DoD were associated with higher risk for ASCVD relative to no DoD. Substance-related disorders were associated with 50% higher risk of incident ASCVD (HR 1.5, 95% CI 1.41 to 1.59), alcohol-related disorders and suicidality/intentional self-harm were associated with 33% and 30% higher risk, respectively (HR 1.33, 95% CI 1.26 to 1.41; HR 1.30, 95% CI 1.11 to 1.52). Co-occurring DoD components conferred higher risk still. The highest risk combination was substance-related disorders+suicidality (HR 2.01, 95% CI 1.44 to 2.82).Conclusions Among this cohort of insured adults, documented DoD was associated with increased ASCVD risk. Further research to understand and address cardiovascular disease prevention in those with DoD could reduce costs, morbidity and mortality. Further examination of overlapping structural factors that may be contributing to concurrent rises in ASCVD and DoD in the USA is needed

Rurality or distance to care and the risk of homelessness among Afghanistan and Iraq veterans

INTRODUCTION: To date, no studies have examined the relationship of rurality and distance to nearest VA facility to risk of homelessness. METHODS: We examined differences in the rate of homelessness within a year of a Veteran's first encounter with the VA following last military separation based on rurality and distance to the nearest VA facility using multivariable log-binomial regressions. RESULTS: In our cohort of 708,120 Veterans, 73% were determined to have a forwarding address in urban areas, 59.2% and 86.7% lived within 40 miles of the nearest VA medical center (VAMC), respectively. Veterans living in a rural area and those living between 20+ miles away from the nearest VAMC were at a lower risk for homelessness. CONCLUSIONS: Our unique dataset allowed us to explore the relationship between geography and homelessness. These results are important to policy makers in understanding the risk factors for homelessness among Veterans and planning interventions