Report Faults Limitations of Research on Rural Vets

Most research on rural veterans' health care needs is inadequate, inconsistent, and out of date, according to a review of recent literature by researchers from the Department of Veterans Affairs. More work must be done to successfully meet the needs of veterans returning from the wars in Iraq and Afghanistan.

A disproportionately high number of military personnel in the current conflicts come from rural areas, boosted by the heavy use of National Guard units and Reserve troops, according to the study, which appeared in the fall 2008 Journal of Rural Health.

“Despite the increased need, rural veterans get less overall care from both the VA and from the private sector,” said lead author William Weeks, M.D., M.B.A., of the White River Junction VA Medical Center in Vermont, in an interview. However, the VA has established the Office of Rural Health and is backing more research from specialized centers recently created in White River Junction, Salt Lake City, and Iowa City, he said.

For the current study, Weeks and colleagues searched the medical literature covering 1950 to 2007 and found 106 U.S. studies about rural veterans. They included the 50 papers that both defined “rural” and analyzed rural veterans. These studies variously covered access to care, distance technology (such as telemedicine), new models of care delivery (such as satellite psychiatric clinics), patient characteristics, program evaluation, and veterans' health services utilization.

Compared with their peers in metropolitan areas, rural veterans have a lower health-related quality of life. They have more physical comorbidities but a lower prevalence of mental health comorbidities. Also, they have less access to care and face greater travel problems obtaining care. Distance may account for lower levels of service utilization in rural areas, even though studies of services found that their quality was at least as good as that in urban areas. Older rural veterans relied on the VA more than on Medicare for health care.

Weeks and colleagues noted several problems with the existing studies. First of all, there was no consistent definition of “rural.” Some studies used a U.S. census definition, while others used state, county, town, ZIP code, or telephone designations. Two studies relied on self-report to define a patient's residence. None used the VA's own classification system, which divides the country into urban, rural, or highly rural settings. The VA has also created a database of patient-level geo-coding (a process that converts street addresses or ZIP codes to latitude and longitude), but it is“ not readily accessible” to researchers outside the VA, said the authors.

Data collected in the studies may also be outdated. Forty-three of the 50 studies used data from 2000 or earlier, and only one was based on information gathered since the Iraq war began in 2003. Just one-third of the studies used a nonrural comparison group. Most studies were retrospective. Only nine studies were prospective, including five looking at distance technology—all of which covered teleconferencing.

Teleconferencing has proven effective in extending mental health services to remote areas, but the technology cannot be used conveniently at home and veterans must travel to the nearest VA outpatient clinic to use it. Technologies using the telephone or an Internet connection might be more useful in linking services to greater numbers of veterans in their homes.

“It will take creative ways to meet the needs of rural veterans because the VA can't open outpatient clinics everywhere,” said Weeks, a psychiatrist. “Maybe the VA could coordinate their care with Medicare or with private providers.”

He acknowledged that many veterans' service organizations are wary of turning VA health benefits into an insurance program, rather than using the dedicated existing system.

“The World War II vets wanted a brick and mortar VA, but younger vets are not so opposed,” he said. “They have more mental health issues but less access to care [because they are too young for Medicare].”

In future research on the medical needs of rural veterans, investigators should choose a standard definition of rurality and, for technical reasons, evaluate data based on both VA geo-coding and on ZIP codes, he said.

“[F]uture studies should use the patient as the unit of analysis [because] VA patients obtain the majority of their health care in non-VA settings,” wrote the authors. “When analyses are limited to VA settings or to care provided only by the VA, they are likely to underestimate utilization and misrepresent utilization patterns.... [A] lack of information about non-VA care limits an understanding of access to care.”

An abstract of “Research on Rural Veterans: An Analysis of the Literature” is posted at<www3.interscience.wiley.com/journal/121421832/abstract>.▪