Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration...

. . . . . Access Issues: Veterans . . . . .

ABSTRACT: Context: The 4.5 million military veterans

treated by the Veterans Health Administration (VA) are

believed to experience poorer physical and mental health

than nonveterans. Furthermore, nonmetropolitan

residents have less access to medical services, whether or

not they are veterans in VA care. A direct comparison of

metropolitan and nonmetropolitan veterans and

nonveterans on a national health survey has not been

reported, so it is not known whether nonmetropolitan VA

patients experience similar medical need or access as other

nonmetropolitan residents. Purpose: We sought to

compare the perceptions of health status and access to care

among metropolitan and nonmetropolitan veterans in VA

care, other veterans, and nonveterans in a large national

sample surveyed under the same conditions. Methods: Male respondents to the 2000 Behavioral Risk Factor

Surveillance System health survey were divided into

veterans or nonveterans, VA users or nonusers,

metropolitan or nonmetropolitan residents, and 1 of 3 age

groups (18-44, 45-64, and 65+). Responses to questions

about current health status, health coverage, and access to

care were submitted to chi-square analyses or analyses of

variance, using SUDAAN software to compute survey

error variance. Findings: Nonmetropolitan VA patients

younger than 65 years consistently reported the worst

physical and mental health status and reduced access to

care. Conclusions: VA can anticipate increasing demand

for mental and physical health care among rural veterans

younger than 65 years.

1 Veterans ’ Rural Health Initiative, VA Medical Center, White River

Junction, Vt.

2 Department of Community & Family Medicine, Dartmouth

Medical School, Hanover, NH.

3 Department of Psychiatry, Dartmouth Medical School, Hanover,

NH.

4 National Center for Patient Safety, Field Offi ce, VA Medical Center,

White River Junction, Vt.

5 VA National Quality Scholars Fellowship Program, VA Medical

Center, White River Junction, Vt.

6 VA Outcomes Group, VA Medical Center, White River Junction, Vt.

This research was supported by the Veterans’ Rural Health

Initiative and by the Department of Veterans Affairs, Veterans

Health Administration, Health Services Research and Development

Service (project REA 03-098). Dr Weeks is the principal investigator

at the WRJ, VT VAMC. The views expressed in this article do not

necessarily represent the views of the Department of Veterans

Affairs or of the United States government. For further

information, contact: Alan West, PhD, Center for Rural Health

Studies (11Q), VA Medical Center, White River Junction, VT 05009;

e-mail [email protected].

Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger Than 65 Years Alan West , PhD ; 1 and William B . Weeks , MD , MBA 1-6

users have been found to experience worse physical health – and mental health – related quality of life than their urban counterparts, regardless of age or other demographics. 3 VA ’ s high technology and specialty health care services, however, are now provided through regional referral centers, typically located in metropolitan areas. Rural veterans must travel far to access this care, and so they often underutilize services. 4,5 Though health care demand is growing throughout our aging population, current combat operations will likely increase future demand for VA services even faster, and the relative disadvantages of nonmetropolitan veterans seeking medical care may well intensify.

Optimal resource allocation must take account of veterans’ perceived health care needs, how these needs relate to factors such as age and area of residence, and

T he Veterans Health Administration (VA) provides comprehensive health care services to 4.5 million US veterans, a predominantly male population that is older, sicker, and more often disabled than

other adults. 1 Since VA ’ s 1996 structural reorganization into Veterans Integrated Service Networks, patient enrollment has grown dramatically, particularly in nonmetropolitan areas, where the highest concentrations of veterans live. 2 Nonmetropolitan VA

© 2006 National Rural Health Association 9 Winter 2006


The Journal of Rural Health 10 Vol. 22, No. 1

how they compare to those of the general urban and nonurban populations. The few relevant studies, however, have examined these issues only partially. National Health Interview Survey data from 1993 and 1994 showed that VA patients have poorer health, more medical conditions, and higher medical resource use than the general patient population, 6 while another recent study found that VA patients in Washington state have poorer health than non-VA patients. 7 Neither study, however, examined urban-rural differences. The most comprehensive comparison of rural and urban veterans’ health status 3 did not include a nonveteran comparison group. To date, no study has reported a direct comparison of metropolitan and nonmetropolitan veterans and nonveterans using the same large-sample health status survey administered nationally under the same conditions and sampling design.

We sought to understand veterans’ perceived health care needs by analyzing the Behavioral Risk Factors Surveillance System (BRFSS), a nationwide health survey of the general adult population conducted annually by the Centers for Disease Control and Prevention. Unlike most years, the BRFSS survey administered in 2000 asked respondents if they were veterans, which allowed us to determine the health status and needs of male VA patients, other veterans not currently in VA care, and nonveterans, and to contextualize those needs in light of age and metropolitan versus nonmetropolitan residence.

Method Sample. The BRFSS is an annual telephone survey

of adults living in households in all 50 US states, the District of Columbia, Puerto Rico, and the Virgin Islands. New participants are selected each year under a stratifi ed random sampling design. All BRFSS interviewees are asked a core set of items (with modifi cations year to year) that assess health status, certain behavioral risks to health, health insurance coverage, and health care access. Raw BRFSS response data, at the level of individual respondents but devoid of identifying information, are available for public download at the BRFSS Web site ( www.cdc.gov/brfss/index.htm ).

BRFSS data include the respondent ’ s age and county of residence. Each year the BRFSS asks whether respondents received health care services from VA facilities during the past year. The BRFSS administered in 2000, however, also asked respondents if they had ever served in the US armed forces (a question that typically is not asked). With these data elements available, the 2000 BRFSS makes it possible to separate

a large, nationally representative, stratifi ed probability sample interviewed under a standardized format into veterans or nonveterans, VA users or nonusers, residents of metropolitan or nonmetropolitan counties, and members of specifi c age categories, and then compare them with respect to self-reported health status, health-related functional limitations, and health care access.

The BRFSS 2000 sample totaled 184,450 individuals, including 109,680 (59.5%) women and 74,770 (40.5%) men. About 1.1% of respondents refused to say whether they had ever been in military service, and another 0.2% did not know. Only 1.2% of women identifi ed themselves as veterans, and only 259 women said they used VA care. Consequently, we restricted all analyses to men, 32.5% of whom (23,998 men) identifi ed themselves as having been in military service. Some of these men were currently on active duty or in the reserves when interviewed, leaving 22,068 men who were no longer in military service; 14.2% of these veterans indicated that they had received health care from VA in the past 12 months. We also separated both veterans and nonveterans into age groups: 18 to 44, 45 to 64, and 65+ years old. With very small proportions of respondents missing age, veteran status, or VA utilization information, we could classify 71,620 men (95.8% of all the men in the BRFSS 2000 sample) into age categories and VA patient, other veteran, or nonveteran groups.

Effect of Residence. Since metropolitan-nonmetropolitan comparisons were of major interest, we also sought to separate respondents by residence. BRFSS data include a Federal Information Processing Standards code for the county in which the respondent lives. We matched these Federal Information Processing Standards codes to the corresponding Rural-Urban Continuum (RUC) codes defi ned by the US Department of Agriculture ’ s Economic Research Service ( www.ers.usda.gov/briefi ng/rurality/RuralUrbCon/ ). The Economic Research Service has classifi ed each US county with a code number from 1 to 9, refl ecting its position on an urban-rural continuum. We matched Federal Information Processing Standards with RUC codes to defi ne each respondent as either a metropolitan (with RUC codes 1-3, representing urban counties or counties whose residents commute to urban areas) or a nonmetropolitan (with RUC codes 4-9, representing counties with towns smaller than 50,000 people) resident.

Unfortunately, county of residence was missing for 34% of all males, who therefore could not be classifi ed as either metropolitan or nonmetropolitan residents, raising the question as to whether the men who can be categorized are representative of the sample as a


West and Weeks 11 Winter 2006

whole. To address this concern, we compared the demographics of respondents with residence information to those of respondents without it, and included demographics as factors in analyses of dependent measures. We analyzed each dependent measure in 2 ways. First, we analyzed the data for all men who could be classifi ed into age categories and VA patient, other veteran, or nonveteran groups, regardless of whether they had residence information. We then reanalyzed using only those subjects for whom residence was available; in this analysis, metropolitan-nonmetropolitan status was included as a factor in addition to age and VA patient, other veteran, or nonveteran status. For both approaches, we also conducted subsidiary analyses that included demographics. The logic was that if age, veteran status, or VA use effects observed on the whole male sample were different from those seen for the reduced sample having residence information, the reduced sample must not represent the full sample well. Similarly, we controlled for demographic differences among the urban, nonurban, and “ missing county ” subjects to assess whether they explained any residence effects. This strategy permitted us not only to test metropolitan-nonmetropolitan differences but also to determine whether missing subjects may have distorted the effects observed. (Of course, some dependent variables also had missing data; if so, subjects with missing data were eliminated from analyses on a variable-by-variable basis.)

Our analyses consistently showed that age and VA patient, other veteran, or nonveteran effects were similar across the 2 forms of analysis, yielding evidence that the reduced sample (ie, the subjects who had residence information) was representative of the whole. Comparing the “ missing county ” individuals to those with residence information, we found several signifi cant, though relatively small, demographic differences: the missing county respondents were more likely to be white (86.7%, vs 83.0% of those with residence information), Hispanic (13.4% vs 7.4%), married (57.3% vs 52.7%), not educated beyond high school (53.2% vs 40.1%), unemployed (40.7% vs 34.6%), and to have low income (58.8% vs 45.6%). Analyses that included demographics as factors, however, yielded few and inconsistent signifi cant effects for them. Therefore, we report only the results of analyses on those subjects for whom residence was available, since metropolitan-nonmetropolitan differences are of focal interest.

Dependent Measures and Statistical Methods. We assessed metropolitan-nonmetropolitan differences among our age-stratifi ed VA patient, other veteran, or nonveteran groups on dependent measures of 3 kinds:

1. The fi rst BRFSS health status question asked subjects to rate (on a 5-point scale from “ Excellent ” to “ Poor ” ) their health in general. We calculated the proportion of respondents who reported poor health.

2. Subjects were asked to estimate days in the prior month that their physical health and mental health were “ not good. ” Those who reported any days for either item also were asked how many days poor health had limited their usual activities, such as self-care, work, or recreation. To simplify these data for graphic display, we collapsed the 3 measures — poor physical health days, poor mental health days, and days that poor health limited activities — into a single measure by taking the maximum of the 3 for each respondent. This measure, maximum poor-health days, refl ects each subject ’ s greatest number of such days per month.

3. Subjects were asked if there had been a time in the past year that they needed to see a doctor but could not because of the cost. They also were asked if they had health insurance coverage, including Medicare, and if they had had a routine checkup during the year. We determined the proportions of respondents who answered affi rmatively to each item.

The BRFSS employs a complex stratifi ed sampling design, with each state split into multiple primary sampling units from which respondents are surveyed randomly. Response data include a summary weighting variable to be applied in statistical tests to partially correct for variations in sampling coverage and to estimate population values. To ensure proper variance estimates, we used SAS-callable SUDAAN software (RTI International, Research Triangle Park, NC), which was developed for analysis of complex sample survey designs. Frequency data were analyzed using chi-square tests, and continuous measures were analyzed via analyses of variance, computed using SUDAAN ’ s Crosstab, Descript, and Regress procedures, applying the BRFSS sampling design and fi nal weighting variable.

Results Table 1 displays the numbers of respondents

by group, age category, and residence, and reveals that a greater proportion of nonmetropolitan than metropolitan respondents were veterans, and a higher proportion of these nonmetropolitan veterans, particularly older men, used VA care (P < .0001 for all). For each combination of group, age, and residence, the table also shows the percentage of respondents in various demographic categories. Among metropolitan VA patients 18 to 44 years old, for example, 42.1% were



nonwhite and 38.0% were married. VA patients were relatively less likely than other respondents to be white or married, and more likely to be unemployed or to have low income (P < .0001 for all). Nonmetropolitan residents were more likely than metropolitan ones to be white, married, less educated, unemployed, and to have low income (P < .0001 for all). Analyses of dependent measures that controlled for these demographics, however, did not alter our results appreciably and therefore are not reported.

Nonmetropolitan VA patients 45 to 64 years old reported the highest rate of poor general health, followed closely by nonmetropolitan VA patients 65 or older ( Figure 1 ). Not surprisingly, VA patients in these age ranges, regardless of residence, also were signifi cantly more likely to report poor health than their counterparts among other male veterans or nonveterans (P < .0001).

Compared to other men, middle-aged (45-64) and older (65+) VA patients reported more recent days of

poor physical health, as revealed by a signifi cant interaction between age and VA patient, other veteran, or nonveteran status (P < .0002). Middle-aged VA users also reported more recent days of poor mental health (P < .0001 for the interaction) and more days of poor health limiting one ’ s usual activities (P < .0001). Though the metropolitan-nonmetropolitan residence factor did not yield signifi cant effects, nonmetropolitan residents consistently averaged more days of poor physical health, more days of poor mental health, and more days of poor health limiting activities.

Maximum poor-health days (ie, each respondent ’ s highest estimate of poor physical health days, poor mental health days, or days of limited activities due to poor health in the past month) were analyzed similarly. In any age group, veterans currently in VA care averaged the most poor-health days in the past month ( Figure 2 ). Age and veteran or VA user status interacted signifi cantly (P < .0001), due to higher estimates given

Counts of Respondents and Percentages (With Standard Errors [SE]) Having Various Demographics By Age Group, Residence, and VA User, Nonuser, or Nonveteran Status

VA Patients Veterans Who Are Not VA Patients Nonveterans

Age group (years) 18-44 45-64 65+ 18-44 45-64 65+ 18-44 45-64 65+

Number of respondents Metro 244 526 587 1,952 4,271 3,251 17,035 6,856 1,560 Nonmetro 68 238 265 529 1,442 1,016 4,471 2,282 592

Nonwhite, % (SE) Metro 42.1 (4.8) 25.8 (3.0) 14.9 (2.2) 23.7 (1.5) 12.1 (0.8) 6.7 (0.7) 24.1 (0.6) 20.4 (0.9) 18.9 (1.6) Nonmetro 25.5 (11.1) 15.5 (3.9) 7.2 (2.3) 13.3 (2.6) 7.4 (1.0) 4.4 (0.8) 15.3 (0.9) 9.3 (0.9) 13.2 (2.1)

Hispanic, % (SE) Metro 11.9 (4.2) 9.7 (2.6) 5.9 (2.6) 9.9 (1.1) 5.5 (0.7) 3.2 (0.8) 19.4 (0.6) 14.0 (1.0) 12.5 (2.5) Nonmetro 5.3 (4.1) 3.0 (1.2) 3.1 (1.2) 5.0 (1.5) 4.1 (0.7) 2.3 (0.6) 7.8 (0.6) 5.5 (0.7) 4.6 (1.1)

Currently married, % (SE) Metro 38.0 (4.4) 57.3 (3.3) 60.0 (3.1) 62.0 (1.6) 75.8 (1.0) 76.1 (1.0) 46.4 (0.6) 73.0 (0.8) 69.9 (1.7) Nonmetro 59.6 (10.6) 66.9 (4.1) 76.5 (3.3) 64.6 (3.3) 80.0 (1.5) 80.6 (1.7) 53.7 (1.1) 76.3 (1.3) 73.7 (2.3)

Education more than high school, % (SE) Metro 63.7 (4.6) 64.2 (3.3) 45.7 (3.1) 62.9 (1.7) 67.9 (1.1) 61.1 (1.2) 61.1 (0.6) 62.8 (1.0) 42.9 (1.9) Nonmetro 72.7 (7.8) 48.3 (4.7) 43.2 (4.9) 50.5 (3.7) 56.3 (2.0) 54.8 (2.3) 48.6 (1.2) 50.8 (1.7) 28.5 (3.0)

Currently employed, % (SE) Metro 78.0 (4.7) 57.0 (3.3) 11.6 (1.9) 91.9 (1.0) 76.2 (1.0) 15.8 (0.9) 85.2 (0.5) 81.3 (0.8) 18.4 (1.5) Nonmetro 55.4 (11.5) 46.1 (4.7) 10.9 (2.3) 90.1 (2.2) 75.7 (1.7) 16.2 (1.7) 83.0 (1.0) 76.9 (1.3) 14.6 (2.0)

Family income <$35,000, % (SE) Metro 40.4 (4.9) 53.6 (3.6) 76.0 (3.0) 30.6 (1.6) 23.6 (1.1) 49.0 (1.4) 36.5 (0.6) 30.0 (1.0) 65.3 (2.0) Nonmetro 67.8 (9.2) 67.7 (5.0) 81.1 (3.7) 48.8 (3.8) 33.1 (2.0) 55.5 (2.7) 51.9 (1.3) 42.7 (1.9) 75.5 (3.4)

Have health insurance, % (SE) Metro 81.3 (4.7) 83.7 (2.3) 96.3 (0.9) 83.3 (1.3) 93.9 (0.6) 99.0 (0.3) 80.3 (0.5) 87.6 (0.7) 96.4 (0.9) Nonmetro 87.0 (6.9) 81.2 (3.8) 94.7 (2.0) 80.9 (2.6) 89.8 (1.2) 99.4 (0.2) 75.1 (1.1) 84.9 (1.4) 94.6 (1.4)

Have Medicare, % (SE) Metro 9.9 (3.8) 22.3 (3.2) 90.5 (1.9) 2.8 (0.6) 5.9 (0.5) 93.6 (0.6) 3.8 (0.3) 8.9 (0.6) 88.7 (1.2) Nonmetro 19.8 (12.6) 37.5 (5.3) 94.7 (2.1) 5.2 (2.0) 7.9 (1.0) 96.6 (0.7) 4.3 (0.5) 11.3 (1.0) 95.0 (1.2)

Example: of metropolitan VA patients, 18 to 44 years old, 42.1% were nonwhite, with a SE of 4.8%.



by VA patients, particularly those in the age range of 45 to 64 years. Residence interacted signifi cantly with veteran or VA patient status (P < .05), as nonmetropolitan VA patients reported especially high numbers of poor-health days.

Table 1 also shows the percentages of respondents with any health care insurance coverage and with Medicare specifi cally. Most respondents (85.7% of all males) said they had some form of coverage, and percentages increased with age. Overall, nonmetropolitan residents had less coverage than metropolitan residents in the age groups of 18 to 44 years (P < .0001) and 45 to 64 years (P < .005). Of respondents 65 or older, 92.1% had Medicare; more nonmetropolitan elderly residents had Medicare than metropolitan elderly residents (P < .0001). Among respondents 45 to 64 years old, VA patients were more likely to have Medicare than other veterans or nonveterans (P < .0001). Among VA patients, nonmetropolitan residents had higher rates of Medicare coverage in the age group of 18 to 44 years (P < .0005) and 45 to 64 years (P < .001).

Figure 3 shows the percentages of men who reported that during the previous year they needed

to see a doctor but could not because of cost. Nonmetropolitan VA patients 18 to 44 years old were the most likely to say so compared to other groups in that age range (P < .005). Among subjects 45 to 64 years old, both metropolitan and nonmetropolitan VA patients were more likely to report that cost kept them from accessing needed treatment. On the other hand, subjects were also asked how long it had been since they had seen a doctor for a routine checkup (not shown in the fi gure). Though most subjects (80.6% overall) reported that it had been within the past 2 years, VA patients reported the highest rate (91.6%; P < .0001). Regardless of age or VA patient, other veteran, or nonveteran status, metropolitan residents (80.7% overall) were slightly more likely than nonmetropolitan ones (78.6%) to have had a checkup within the past 2 years (P < .01).

Discussion This study is the fi rst direct comparison of veterans

in VA medical care to other veterans or nonveterans in a national survey of health problems, health-related

Figure 1. BRFSS 2000 — All Males. Percentages (With Standard Errors) of Respondents Who Reported Poor General Health. By Veteran — VA User Status, Residence, and Age Group.

0

10

20

30

Metro Non-Metro Metro Non-Metro Metro Non-Metro

Veterans Currently in VA Care Veterans Not in VA Care Non-Veterans

18 to 44 45 to 64 65+



functional limitations, and health care access. Not surprisingly, VA patients reported poorer health and more days of both physical and mental health problems than other veterans or nonveterans, since these other groups were not limited to men who had used health care recently. More noteworthy, however, are the consistent fi ndings that VA patients living in nonmetropolitan areas reported worse health, more functional impairment, and less access to care than their metropolitan counterparts or the other survey respondents. In particular, nonmetropolitan VA patients younger than 65 years reported the highest levels of both physical and mental health problems, and greater disability (which is also refl ected in higher Medicare enrollment), yet more diffi culty accessing care due to cost.

These fi ndings have implications for the allocation of resources to meet the health care needs of veterans across the country. They confi rm that VA patients perceive their health care needs to be substantially greater than do nonveterans or veterans not in VA care. Though patient enrollment has grown in recent years, this expansion does not appear to have diluted the

average illness burden of VA ’ s clientele. Our fi ndings also corroborate a concern that living at a distance from regionalized health care implicitly restricts access to and utilization of health services. 4,5 Veterans may have an additional health care option not available to the general public, but those veterans who live in nonmetropolitan areas, far from regionalized high technology or specialized care, continue to experience substantial unmet needs, greater than those of veterans in metropolitan settings. VA has tried to address these needs by instituting community-based outpatient clinics in less populated settings, 8 but their services are restricted largely to primary care, which may not adequately meet the additional health care needs of nonmetropolitan veterans. Given Census Bureau data that the highest concentrations of veterans live in rural and nonmetropolitan counties, and the likelihood that many more veterans with medical needs will soon be returning from the Middle East, VA can anticipate increasing demand for mental and physical health care among younger nonmetropolitan veterans.

Younger VA patients in nonmetropolitan areas are more likely than metropolitan patients to have

Figure 2. BRFSS 2000 — All Males. Means (With Standard Errors) of the Maximum Number of Days in the Past 30 of Poor Physical Health, Poor Mental Health, or Poor Health Limiting Activities. By Veteran — VA User Status, Residence, and Age Group.

0

5

10

15



18 to 44 45 to 64 65+



Medicare and no less likely to have medical insurance, yet they are more likely to report not seeking needed medical care because of its cost. Since medical insurance seldom provides full coverage, and given the lower income and employment rates of the younger nonmetropolitan VA patients, we suspect that the burden of meeting copayment requirements limits their access to care. Perhaps a coordinated federal benefi t program, combining VA and Medicare resources, could reduce the copayment burden and improve health care access. In any event, VA must develop new approaches for delivering care, and for coordinating care with non-VA providers, to meet the needs of veterans in nonmetropolitan settings.

Our fi ndings have several limitations: BRFSS data are self-reports and are sampled only from households with telephones, which may limit their generalizability. Second, we analyzed data for males only. Women are now enlisting in the military and using VA in greater numbers, but they still represent less than 5% of VA ’ s clientele. Because there were too few women to include, our fi ndings may not generalize to female

veterans. Third, because the BRFSS sampling strategy did not oversample veterans or those in rural settings, our conclusions, albeit statistically signifi cant, are based on relatively few nonmetropolitan VA-using respondents. Our fi ndings, however, were consistent across multiple measures, and with previous studies that have found greater mental health care needs among younger veterans 9 and greater physical and mental health care needs in rural VA users. 3 In future BRFSS surveys, oversampling of veterans, perhaps by concurrently administering these within the VA service population, may help VA allocate resources to meet veterans’ health needs and contextualize them within those of the general population.

Despite these limitations, our analysis of national health survey data suggests that there may be unmet health care needs among nonmetropolitan veterans who use the VA. Given the many combat veterans with substantial mental and physical health care needs who are returning to the United States, we anticipate that demand for VA health care in nonmetropolitan areas, particularly among younger veterans, will increase

Figure 3. BRFSS 2000 — All Males. Percentages (With Standard Errors) of Respondents Who Needed to See a Doctor in the Past Year but Could not Because of the Cost. By Veteran — VA User Status, Residence, and Age Group.

0

10

20

30

40



18 to 44 45 to 64 65+



dramatically in coming years. Policy makers should consider these factors in planning future health care services.

References 1. Wilson N , Kizer K . The VA health care system: an unrecognized

national safety net . Health Aff . 1997 ; 16 : 200 - 204 . 2. US Census Bureau . Veterans: 2000. Census 2000 brief . Available

at : http://www.census.gov/prod/2003pubs/c2kbr-22.pdf . Accessed May 2003 .

3. Weeks WB , Kazis LE , Shen Y , Cong Z , Ren XS , Miller D , Lee A , Perlin JB . Differences in health-related quality of life in rural and urban veterans . Am J Public Health . 2004 ; 94 : 1762 - 1767 .

4. Burgess J , DeFiore D . The effect of distance to VA facilities on the choice and level of utilization of VA outpatient services . Soc Sci

Med . 1994 ; 39 : 95 - 104 . 5. Mooney C , Zwanziger J , Phibbs C , Schmitt S . Is travel distance a

barrier to veterans’ use of VA hospitals for medical surgical care . Soc Sci Med . 2000 ; 50 : 1743 - 1755 .

6. Agha Z , Lofgren RP , VanRuiswyk JV , Layde PM . Are patients at Veterans Affairs medical centers sicker? Arch Intern Med . 2000 ; 160 : 3252 - 3257 .

7. Koepsell T , Reiber G , Simmons WK . Behavioral risk factors and use of preventive services among veterans in Washington State . Prev Med . 2002 ; 35 : 557- 562 .

8. Fortney J , Borowsky S , Hedeen A , Maciejewski M , Chapko M . VA community-based outpatient clinics: access and utilization performance measures . Med Care 2002 ; 40 : 561 - 569 .

9. Kazis LE , Ren XS , Lee A , Skinner K , Rogers W , Clark J , Miller DR . Health status in VA patients: results from the Veterans Health Study . Am J Med Qual . 1999 ; 14 : 28 - 38 .

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