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Background: The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans., Methods: We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care., Results: Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care., Conclusions: This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Objective: The purpose of this study was to derive and describe subtypes of Pain Outcomes Questionnaire (POQ) profiles produced by a large, heterogeneous multisite sample of chronic pain patients (N = 672)., Methods: The POQ core scales were subjected to Ward's hierarchical agglomerative cluster analyses in order to establish the optimal number of clusters in validation (N = 336) and cross-validation (N = 336) subsamples. Based on the consistency of the solutions derived from the two subsamples, a third Ward's procedure was performed on the entire sample and, finally, a K-means iterative partitioning procedure was used to assign cases to the cluster groups. The resulting cluster solution was validated using a broad range of demographic, pain, and treatment outcomes data., Results: The cluster analytic procedure revealed the presence of eight unique subgroups of POQ profiles. The adequacy of the final solution was demonstrated using a multivariate analysis of variance and a discriminant function analysis. Group differences on the demographic and pain variables were generally consistent with expectations based on mean profiles, and therefore, provided evidence of the validity of the cluster solution. Brief descriptions of each cluster group were generated based on the correlate data. The clinical utility of the solution was in part demonstrated by differential treatment response rates among the groups., Discussion: The results of this study are generally consistent with those of previous cluster analytic investigations of pain patients and suggest that psychosocial/behavioral classification systems may serve a useful heuristic function in the assessment and treatment of chronic pain that is not provided by current diagnostic taxonomies.

Objective: Pain is one of the most frequently reported symptoms by veterans returning from recent overseas military actions. The purpose of the current study was to obtain a preliminary estimate of the prevalence and severity of pain among veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF; N=970). The demographic, etiologic, and diagnostic characteristics of 100 veterans with moderate to severe chronic pain conditions were examined in order to provide a description of this new group of pain patients., Design: This was a historical cohort study that utilized electronic medical record review for all data collection., Patients: All registered OEF/OIF veterans seeking treatment at a Southeastern Veterans' Affairs medical center were included in the initial cohort. In order to describe the characteristics of those with clinically significant pain, 100 veterans were randomly sampled from the subset of patients who reported moderate to severe chronic pain intensity during a medical visit (N=219)., Results: Approximately 47% of veterans whose charts included pain score documentation (N=793) reported at least a mild level of current pain. Moderate to severe pain intensity was recorded for 28% (N=219) of those in the initial cohort with pain scores. Diagnoses of musculoskeletal and connective tissue disorders were recorded for 82% of those with chronic conditions (i.e., duration>or=1 month)., Conclusions: The results of this preliminary study suggest that a substantial percentage of OEF/OIF veterans will experience clinically significant pain following their military service.

The development of effective pain treatment strategies requires the availability of precise and practical measures of treatment outcomes, the importance of which has been noted in the Veterans Health Administration's (VHA's) National Pain Initiative. This paper presents the results of a 5-year collaborative effort to develop and validate a comprehensive and efficient self-report measure of pain treatment outcomes. Two samples of veterans (957 total subjects) undergoing inpatient or outpatient pain treatment at six VHA facilities completed Pain Outcomes Questionnaire-VA (POQ-VA) items and several additional measures. We used a comprehensive, multistage analytic procedure to evaluate the psychometric properties of the instrument. Results provided strong support for the reliability, validity, and clinical use of the POQ-VA when used to evaluate the effectiveness of treatment for veterans experiencing chronic noncancer pain.

The Gay, Lesbian, Bisexual, and Transgender (GLBT) Health Access Project is a unique public-private collaboration working to eliminate barriers to health care for the GLBT community, foster development of comprehensive, culturally appropriate health promotion policies and health care services for GLBT people and their families, and expand appropriate data collection on GLBT health. Funded by the Massachusetts Department of Public Health, the project developed community standards of practice for provision of quality health care services to GLBT clients. A health access training curriculum was developed and technical assistance was offered to health care providers implementing the standards, which cover personnel, clients' rights, intake and assessment, service delivery and planning, confidentiality, and community outreach and health promotion. Training participants (324 individuals from 89 agencies) reported positive though not statistically significant changes in attitude.

The U.S. Environmental Protection Agency is proposing a regulation for the protection of the public from radioactive contamination at sites that are to be cleaned up and released for public use. The rule will apply to sites under the control of Federal agencies, and will impose limits on radiation doses to individuals living or working on a site following cleanup; it will thereby provide site owners and managers with uniform, consistent cleanup criteria for planning and carrying out remediation. This paper presents an overview of EPA's approach to assessing some of the beneficial and adverse effects associated with various possible values for the annual dose limit. In particular, it discusses the method developed to determine how the choice of cleanup criterion affects (1) the time-integrated potential numbers of non-fatal and fatal radiogenic cancers averted among future populations, (2) the occurrence of radiogenic cancers among remediation workers and the public caused by the cleanup process itself, and (3) the volumes of contaminated soil that may require remediation. The analytic methods described here were used to provide input data and assumptions for the Regulatory Impact Analysis (RIA) that supports the proposed regulation; the RIA also considered non-radiological benefits and costs (i.e., public health, economic, and ecological) of the standards.

This article reviews legislative options to prevent the transmission of HIV infection. It distinguishes between pre-exposure measures designed to prevent initial exposure, and post-exposure measures aimed at preventing infected individuals from exposing others. Part I identifies education as the key component of a comprehensive prevention program, and reviews options for pre-exposure education programs designed to avoid or minimize exposure. Part II reviews post-exposure prevention measures, focusing on reporting and contact tracing provisions. Mandatory reporting by name of individuals testing HIV positive and mandatory contact tracing are opposed as counterproductive prevention measures; voluntary partner notification is supported. Part III examines various prevention efforts for settings where there may be either a real or perceived risk of transmission of HIV infection. Part IV sets out conclusions.