Original Research

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

Personality disorders (PDs) are enduring patterns of internal experience and behavior that differ from cultural norms and expectations, are inflexible and pervasive, have their onset in adolescence or early adulthood, and lead to distress or impairment. Ten PDs are included in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition): paranoid, schizoid, schizotypal, borderline, antisocial, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.¹ These disorders impose a high burden on patients, families, health care systems, and broader economic systems.^2,3 Up to 1 in 7 persons in the community and 50% of those receiving outpatient mental health treatment experience a PD.^4,5 These conditions are associated with an increased risk of adverse events, including suicide attempt and death by suicide, criminal-legal involvement, homelessness, substance use, underemployment, relational issues, and high utilization of psychiatric services.^6-9 PDs are routinely underassessed, underdocumented, and undertreated in clinical settings, and consistently receive less research funding than other, less prevalent forms of psychopathology. ^10-12 As a result, there is limited understanding of clinical needs of individuals experiencing PDs.

MILITARY VETERANS WITH PERSONALITY DISORDERS

Underacknowledgment of PDs and their associated difficulties may be especially pronounced in veteran populations. Due to longstanding etiological theories that implicate childhood trauma and adolescent onset in pathology development, PDs are traditionally considered pre-existing conditions or developmental abnormalities by the US Department of Defense and US Department of Veterans Affairs (VA). As a result, PDs are therefore deemed incompatible with military service and ineligible for service-connected disability benefits.^13-15 Such determinations allowed PD pathology to be used as grounds for discharge for 26,000 service members from 2001 to 2007, or 2.6% of total enlisted discharges during that period.^13,15,16

Despite this structural discrimination, recent research suggests veterans may be more likely to experience PD pathology than the general population.17 For example, a 2021 epidemiological survey in a community-based veteran sample found elevated rates of borderline, antisocial, and schizotypal PDs (6%-13%).⁶ In contrast, only 0.8% to 5.0% of veteran electronic health records (EHRs) have a documented PD diagnosis.^8,18,19 Such elevations in PD pathology within veteran samples imply either a disproportionately high prevalence among enlistees (and therefore missed during recruitment procedures) or onset following military service, possibly due to exposure to traumatic events and/ or occupational stress.¹⁷ Due to the relative infancy of research in this area and a lack of longitudinal studies, etiology and course of illness for personality pathology in veterans remains largely unclear.

Structural underacknowledgment of PDs among military personnel has contributed to their underrepresentation in research on veteran populations. PD-focused research with veterans is rare, despite a rapid increase in broader empirical attention paid to these conditions in nonveteran samples.²⁰ A recent meta-analysis of veterans with PDs identified 27 studies that included basic prevalence statistics. PDs were rarely a primary focus for these studies, and most were limited to veterans seen in Veterans Health Administration (VHA) settings.¹⁷ The literature also paints a bleak picture, suggesting veterans who experience PDs are at higher risk for suicide attempt and death by suicide, criminal-legal involvement, and homelessness. They also tend to experience more severe comorbid psychopathological symptoms and more often use high-intensity mental health services (eg, care within emergency departments or psychiatric inpatient settings) than veterans without PD pathology.^6,8,18,19,21 However, PD pathology does not appear to impede the effectiveness of treatment for veterans.^22-24 The implications of PD pathology on broader psychosocial functioning and health care needs certify a need for additional research that examines patterns of personality pathology, particularly in veterans outside the VHA.

METHODS

This study aims to enhance understanding of veterans affected by PDs and offer insight and guidance for treatment of these conditions in federal and nonfederal treatment settings. Previous research has been largely limited to VHA care-receiving samples; the longstanding stigma against PDs by the US military and VA may contribute to biased diagnosis and documentation of PDs in these settings. A large sample of veterans receiving community-based mental health care was therefore used to explore aims of the current study. This study specifically examined demographic patterns, diagnostic comorbidity, psychosocial outcomes, and treatment care settings among veterans with and without a PD diagnosis. Consistent with previous research, we hypothesized that veterans with a PD diagnosis would have more severe mental health comorbidities, poorer psychosocial outcomes, and receive care in higher intensity settings relative to veterans without a diagnosis.

Data for the sample were drawn from the Mental Health Client-Level Data, a publicly available national dataset of nearly 7 million patients who received mental health treatment services provided or funded through state mental health agencies in 2022.²⁵ The analytic sample included about 2.5 million patients for whom veteran status and data around the presence or absence of a PD diagnosis were available. Of these patients, 104,198 were identified as veterans. Veteran patients were identified as predominantly male (63%), White (71%), non-Hispanic (90%), and never married (54%).

Measures

The parent dataset included demographic, clinical, and psychosocial outcome information reported by treatment facilities to individual state administrative systems for each patient who received services. To protect patient privacy, only nonprotected health information is included, and efforts were made throughout compilation of the parent dataset to ensure patient privacy (eg, limiting detail of information disseminated for public access). Because the parent dataset does not include protected health information, studies using these data are considered exempt from institutional review board oversight.

Demographic information. This study reviewed veteran status, sex, race, ethnicity, age, education, and marital status. Veteran status was defined by whether the patient was aged ≥ 18 years and had previously served (but was not currently serving) in the military. Patients with a history of service in the National Guard or Military Reserves were only classified as veterans if they had been called or ordered to active duty while serving. Sex was operationalized dichotomously as male or female; no patients were identified as intersex, transgender, or other gender identities.

Clinical information. Up to 3 mental health diagnoses were reported for each patient and included the following disorders: personality, trauma and attention-deficit/hyperactivity, stressor, anxiety, conduct, delirium/dementia, bipolar, depressive, oppositional defiant, pervasive developmental, schizophrenia or other psychotic, and alcohol or substance use. Mental health diagnosis categories were generated for the parent dataset by grouping diagnostic codes corresponding to each category. To protect patient privacy, more detailed diagnostic information was not available as part of the parent dataset. Although the American Psychiatric Association recognizes 10 distinct PDs, the exact nature of PD diagnoses was not included within the parent dataset. PD diagnoses were coded to reflect the presence or absence of any such diagnosis.

A substance use problem designation was also provided for patients according to various identification methods, including substance use disorder (SUD) diagnosis, substance use screening results, enrollment in a substance use program, substance use survey, service claims information, and other related sources of information. A severe mental illness or serious emotional disturbance designation was provided for patients meeting state definitions of these designations. Context(s) of service provision were coded as inpatient state psychiatric hospital, community-based program, residential treatment center, judicial institution, or other psychiatric inpatient setting.

Psychosocial outcome information. Patient employment and residential status were also included in analyses. Each reflected status at the time of discharge from services or end of reporting period; employment status was only provided for patients receiving treatment in community-based programs.

Data Analysis

Descriptive statistics and X² analyses were used to compare demographic, clinical, and psychosocial outcome variables between patients with and without PD diagnoses. These analyses were calculated for both the 104,198 veterans and the 2,222,306 nonveterans aged ≥ 18 years in the dataset. Given the sample size, a conservative α of .01 was used to determine statistical significance.

RESULTS

In this sample of persons receiving state-funded mental health care, veterans were significantly less likely than nonveterans to have a documented PD diagnosis (2.1% vs 3.6%, X² [1] = 647.49; P < .01). PD diagnoses were more common among White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03) veterans who were in middle to late adulthood (RR, 1.16-1.40), more educated (RR, 1.35), and divorced or widowed (RR, 1.43), and less common among Black/African American (RR, 0.78) or Puerto Rican (RR, 0.32) veterans who were in early adulthood (RR, 0.31-0.79), less educated (RR, 0.64-0.89), and currently married (RR, 0.89) or never married (RR, 0.86). Veteran men and women were equally likely to have a PD diagnosis (RR, 1.03) (Table 1). Among nonveterans, men were less likely than women to have a PD diagnosis (RR, 0.79), and PD diagnoses were most common among persons in middle adulthood (RR, 1.06-1.15) (eAppendix 1).

Veterans with a PD diagnosis were more likely than those without a diagnosis to have more diagnoses (RR, 2.96-8.49) and to have comorbid trauma or related stressor (RR, 1.33), or bipolar (RR, 1.56) or psychotic (RR, 1.15) disorder diagnoses, but less likely to have comorbid depressive disorder (RR, 0.82). Although veterans with and without a PD diagnosis were similarly likely to have a comorbid SUD (RR, 1.13), those with a PD diagnosis were significantly less likely to be assigned a substance use problem designation (RR, 0.78). PD diagnosis was also more common among veterans who received services in state psychiatric hospitals (RR, 3.05), community-based clinics (RR, 1.06), and judicial institutions (RR, 6.33) and less common among those who received services in other psychiatric inpatient settings (RR, 0.30). No differences were observed for residential treatment settings (RR, 0.79). Among nonveterans, a PD diagnosis was associated with slightly greater odds of a substance use designation (RR, 1.03) (eAppendix 2).

Veterans with a PD diagnosis were also less likely to have full-time employment (RR, 0.73) and more likely to have undifferentiated employment (RR, 2.00) or to be removed from the labor force (RR, 1.35). Veterans with a PD diagnosis were also more likely to reside in nontraditional living conditions (RR, 1.42) and less likely to be residing in a private residence (RR, 0.98), compared with those without PD diagnosis. The rates of homelessness were similar for veterans with and without a PD diagnosis (RR, 0.90) (Table 2). These patterns were similar among nonveterans.

DISCUSSION

This study examined the rate and correlates of PD diagnosis among a large, community-based sample of veterans receiving state-funded mental health care. About 2% of veterans in this sample had a PD diagnosis, with diagnoses more common among veterans who were White, non-Hispanic, aged ≥ 45 years, with higher education, divorced or widowed, also diagnosed with trauma-related, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in state psychiatric hospital, community-based clinic, or judicial system settings.

The observed rate of PD diagnosis in this study aligns with what is typically observed in VHA EHRs.^8,18,19 However, the rate is notably lower than prevalence estimates for psychiatric outpatient settings (about 50%) and in meta-analyses of prevalence among veterans (0.8%-23% for each of the 10 PDs).^4,17,26 Longstanding stigma against PDs may contribute to underdiagnosis. For example, many clinicians are concerned that documentation or disclosure of a PD will interfere with the patient’s ability to access treatment due to stigma and discrimination.^27,28 These fears are not unfounded; even among clinicians, PDs are commonly considered untreatable, and many individuals with PDs are denied access to evidence-based treatments due to the diagnosis.²⁹ In a 2016 survey of community psychiatrists, nearly 1 in 4 reported that they avoid taking patients with a borderline PD diagnosis in their caseloads.²⁸ To date, no studies have been conducted to explore clinicians’ willingness to accept patients with other PDs or, specifically, among veterans.

Despite such widespread stigma, research suggests clinicians' negative attitudes toward PDs can be decreased through antistigma campaigns.³⁰ However, it remains unclear if such efforts also contribute to an increase in clinicians’ willingness to document PD diagnoses. Without accurate identification and documentation, the field’s understanding of PDs will remain limited.

In the current study, veterans with PD diagnoses tended to present with more complex and severe psychiatric comorbidities compared to veterans without such diagnoses. Observed comorbidity of PDs (particularly borderline PD) with trauma-related and bipolar disorders is well established.8 Conversely, co-occurring personality and psychotic disorders—which comprise 16% of veterans with a PD diagnosis in the sample in this study—are not consistently examined in the literature. A 2022 examination of veterans receiving VHA care suggested 12% and 13% of those with a PD diagnosis documented in their EHR also had documented schizophrenia or another psychotic disorder, respectively. PD diagnoses were associated with 6.88- and 9.80-fold increases in risk for comorbid schizophrenia and other psychotic disorder diagnoses, respectively.⁸ Similarly, a recent longitudinal study of nearly 2 million Swedish individuals suggested borderline PD is specifically associated with a > 24-times greater risk of having a comorbid psychotic disorder.³¹ It is therefore possible that the comorbidity between personality and psychotic disorders is quite common despite its relative lack of attention in empirical research.

Veterans with PD diagnoses in this study were also more likely to experience substandard housing, employment challenges, and receive treatment through judicial institutions than those without a PD diagnosis. Such findings are consistent with previous research demonstrating the substantial psychosocial challenges associated with PD diagnosis, even after controlling for comorbid conditions.^7,9 Veterans with PDs may benefit from specialized case management and support to facilitate stable housing and employment and to mitigate the risk of judicial involvement. Some research suggests veterans with PDs may be less likely to gain competitive employment after participating in VA therapeutic and supportive employment services programs, suggesting standard programming may be less suitable for this population.³² Similarly, other research suggests individuals with PDs may benefit more from specialized, intensive services than standard clinical case management.³³ Future research may therefore benefit from clarifying the degree to which adaptations to standard programming could yield beneficial effects for persons with PD diagnoses.

Implications

Cumulatively, the results of this study attest to the necessity for transdiagnostic treatment planning that includes close collaboration between psychotherapeutic, pharmacological, and case management services. Some psychotherapy models for PDs, such as dialectical behavior therapy (DBT), which includes a combination of group skills training, individual therapy, as-needed phone coaching, and therapist consultation, may be successfully adapted to include this collaboration.^34-36 However, implementation of such comprehensive programming often requires extensive clinician training and coordination of resources, which poses implementation challenges.^37-39 In 2021, the VHA began large-scale implementation of PD-specific psychotherapy for veterans with recent suicidal self-directed violence and borderline PD, including DBT, though to date results remain unclear.⁴⁰ Generalist approaches, such as good psychiatric management (GPM), which emphasizes emotional validation, practical problem solving, realistic goal setting, and relationship functioning within the context of standard care appointments, may be more easily implemented in community care settings due to lesser training and resource requirements and can also be adapted to include needed elements of care coordination.^41,42 Both DBT and GPM were initially developed for the treatment of borderline PD. Although DBT has also demonstrated some effectiveness in the treatment of antisocial PD, potential applications of DBT and GPM to other PDs remain largely underdeveloped.^43-46

There are no widely accepted medications for the treatment of PDs. Pharmacotherapy for these conditions typically consists of individualized approaches informed by personal experience that attempt to balance targeting of specific symptoms while minimizing polypharmacy and potential risks (eg, overdose or addiction).^47,48 Despite this, pharmacotherapy is often considered a necessary component in the treatment of bipolar and psychotic disorders, both common comorbidities of PDs found in veterans in this study.^49,50 Careful consideration of complex comorbidities and pharmacotherapy needs is warranted in the treatment of veterans with PDs. Future research may benefit from clarifying clinical guidelines around pharmacotherapy, particularly for observed comorbidities of PDs to trauma, bipolar, and psychotic disorders.

It is important to note the discrepancies in the results of this study surrounding patient substance use. The results suggest a negligible or inverse association between the likelihood of a PD diagnosis and difficulties with substance use among the veterans in this study. However, the unexpectedly low rate of SUD diagnoses (< 6%) suggests that they were likely underdocumented. Research suggests a strong association between personality and SUDs in both veteran and civilian samples.^6,51 Results suggesting a lower prevalence of substance use difficulties among treatment-seeking veterans with PDs should be interpreted with great caution.

Demographically, PD diagnoses were more common among veterans who were White, non-Hispanic, and aged ≥ 45 years, and less common among veterans who were Black/ African American, mixed/unspecified race, Puerto Rican or other non-Mexican Hispanic ethnicity, or aged < 35 years. No significant sex-based differences were observed. These patterns are consistent with research suggesting individuals who identify as Black may be less likely than individuals who identify as White to report PD symptoms, meet criteria for a PD, and have a PD diagnosed even when it is warranted.⁵²

The findings observed in this study with respect to age, however, are notably inconsistent with the literature. Previous research typically suggests a negative association between age and PD pathology; however, a 2020 review of PDs in older adults by Penders et al suggests a prevalence of 11% to 15% in this population.^53,54 Research into PDs most often focuses on adolescent and early adulthood developmental periods, limiting insight into the phenomenology of PDs in middle to late adulthood.⁵⁵ Further, most research into PDs among geriatric populations has focused on psychometric assessment rather than practical treatment guidance.⁵⁴ However, in this study, elevated risk for PD diagnoses was salient throughout middle to late adulthood among veterans; similar, albeit less pronounced patterns were also observed for elevated risk of PD diagnosis in middle adulthood among nonveterans. Such findings suggest clarifying the phenomenology and treatment needs of individuals with PDs in middle to late adulthood may have particularly salient implications for the mental health care of veterans affected by these conditions. As the veteran population advances in age, these needs will present unique challenges if health care systems are unprepared to effectively address them.

Limitations

This study is characterized by several strengths, most notably its use of a large dataset recently collected on a national scale. Few studies outside of the VHA system include samples of > 100,000 treatment-seeking veterans collected on a national scale. Nevertheless, results should be understood within the context of several methodological limitations. However, the dataset was limited to the first 3 diagnoses documented in patients’ EHRs, and many patients had no listed diagnoses. Patients with complex comorbidities may have > 3 diagnoses; for these individuals, data provided an incomplete picture of clinical presentation. This is especially relevant for individuals with PDs, who tend to meet criteria for a range of comorbid conditions.^8,10 The now dated practice of listing PDs on Axis II also increases the chance of clinicians listing PDs after conditions traditionally listed on Axis I (eg, major depressive disorder) in patient charts.⁵⁶ This study’s inclusion of only the first 3 listed diagnoses likely underestimated true PD diagnosis prevalence.

The results of this study must be interpreted as reflecting the prevalence and correlates of receiving a PD diagnosis rather than meeting diagnostic criteria for a PD. Relatedly, PD diagnoses were reported as a single construct, limiting insight into prevalence and correlates of individual PD diagnoses (eg, borderline vs paranoid PDs). Meta-analyses estimates suggest PD prevalence among veterans is likely much higher than observed in this study.¹⁷ Stigma continues to discourage clinicians from documenting and disclosing PD diagnoses even when warranted.^27,28 Continued research should aim to clarify conditions (eg, patient presentation, stigma, or institutional culture) contributing to documentation of PD diagnoses. Given the cross-sectional nature of this study, results cannot speak to longitudinal treatment outcomes or prognosis of persons receiving a PD diagnosis.

Despite its large sample size and national representation, the sampling strategy of this study could have contributed to idiosyncrasies in the dataset. Restriction of data to the persons receiving state-funded mental health services introduces a notable bias to the composition of the sample, which is likely comprised of a disproportionately high number of Medicaid recipients, students, and individuals with chronic illnesses and underrepresentation of persons who pay for mental health services using private insurance or private pay arrangements. As such, although socioeconomic information was not provided within this dataset, one can presume a generally lower socioeconomic status among study participants compared to the community at large. This study also included a proportionally small sample of veterans (3.6% compared to about 6.2% in the broader US population), suggesting veterans may have been underrepresented or underidentified in surveyed mental health care settings.⁵⁷ This study also did not include data around service in active-duty military, national guard, or military reserves; a greater proportion of the sample likely had a history of military service than was represented by veteran status designation. Further, the proportionally high sample of individuals with severe mental illness suggests a likely overrepresentation of such conditions in surveyed settings.

Institutional differences in the practice of assigning diagnoses likely limited statistical power to detect potentially meaningful associations and effects. Structural influences, such as stigma and institutional culture, may have notable effects on documentation practices, particularly for PDs. Future research should aim to replicate observed associations using more controlled diagnostic procedures.

Lastly, even with the use of a more conservative α and a focus on effect sizes to guide interpretation of results, use of multiple bivariate analyses can be presumed to have increased the likelihood of type I error. Given the limited prior research in this area, an exploratory approach to statistical analysis was considered warranted to maximize opportunity for identifying areas in need of additional empirical attention. Continued research using more conservative statistical approaches (eg, multivariate analyses) is needed to determine replicability and generalizability of observed results.

CONCLUSIONS

This study examined the prevalence and correlates of PD diagnoses in a national sample of veterans receiving community-based, state-funded mental health care. About 2% received a PD diagnosis, with diagnoses most common among veterans who were White, non-Hispanic, aged ≥ 45 years, also diagnosed with trauma-based, bipolar, and/or psychotic disorders, underemployed, nontraditionally housed, and receiving treatment in a state psychiatric hospital or judicial system setting. The results attest to a necessity for transdiagnostic treatment planning and care coordination for this population, with particular attention to psychosocial stressors.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

The Veterans Health Administration (VHA) is the largest US integrated health system, providing care to veterans through VHA and non-VHA practitioners and facilities.^1,2 Providing high-quality, timely, and veteran-centric care remains a priority for the VHA. Legislative efforts have expanded opportunities for eligible veterans to receive care in the community purchased by VHA, known as community care (CC).¹ The Veterans Access, Choice, and Accountability Act of 2014 came in response to reports of long wait times and drive times for patients.^3-5 The MISSION Act of 2018 expanded access to CC by streamlining it and broadening eligibility criteria, especially for veterans in rural communities who often experience more barriers in accessing care than veterans living in urban communities.^1,6-10 Since the implementation of the Choice and MISSION Acts, > 2.7 million veterans have received care through community practitioners within the VHA CC network.¹¹

Background

Increased access to CC could benefit veterans living in rural communities by increasing care options and circumventing challenges to accessing VHA care (ie, geographic, transportation, and distance barriers, practitioner and specialist shortages, and hospital closures). ^5,9,10,12,13 However, health care system deficits in rural areas could also limit CC effectiveness for veterans living in those communities. ³ Other challenges posed by using CC include care coordination, information sharing, care continuity, delayed payments to CC practitioners, and mixed findings regarding CC quality.^5,8,13,14 VHA practitioners are specifically trained to meet the multifaceted needs unique to veterans’ health and subculture, training CC practitioners may not receive.^5,15

CC offers services for primary care and a broad range of specialties, including rehabilitation services such as physical therapy (PT).⁶ PT is used for the effective treatment of various conditions veterans experience and promote wellbeing and independence.¹⁶ US Department of Veterans Affairs (VA) databases reveal a high prevalence of veterans receiving PT services through CC; PT is one of the most frequently used CC outpatient specialty services by veterans living in rural communities.^14,17

Telerehabitltation Enterprisewide Initiative

VHA has greatly invested in delivering care virtually, especially for veterans living in rural communities.¹⁸ In 2017, the VHA Office of Rural Health funded the Telerehabilitation Enterprise-Wide Initiative (TR-EWI) in partnership with the Physical Medicine and Rehabilitation Services national program office to increase access to specialized rehabilitation services for veterans living in rural communities by leveraging telehealth technologies.^18-21 This alternative mode of health care delivery allows clinicians to overcome access barriers by delivering rehabilitation therapies directly to veterans' homes or nearby community-based outpatient clinics. TR-EWI was conceived as a hub-and-spoke model, where rehabilitation expertise at the hub was virtually delivered to spoke sites that did not have in-house expertise. In subsequent years, the TR-EWI also evolved to provide targeted telerehabilitation programs within rural-serving community-based outpatient clinics, including PT as a predominant service.^19,20

As TR-EWI progressed—and in conjunction with the uptake of telehealth across VHA during the COVID-19 pandemic—there has been increased focus on PT telerehabilitation, especially for the 4.6 million veterans in rural communities.^18,22,23 Because health care delivery system deficits in rural areas could limit the effective use of CC, many TR-EWI sites hope to reduce their CC referrals by providing telehealth PT services to veterans who might otherwise need to be referred to CC. This strategy aligns with VHA goals of providing high-quality and timely care. To better understand opportunities for programs like TR-EWI to provide rehabilitation services for veterans and reduce care sent to the community, research that examines CC referral trends for PT over time is warranted.

This study examines CC from a rehabilitation perspective with a focus on CC referral trends for PT, specifically for Veterans Integrated Service Networks (VISNs) where TREWI sites are located. The study’s objectives were to describe rehabilitation PT services being referred to CC and examine associated CC costs for PT services. Two research questions guided the study. First, what are the utilization trends for CC PT referrals from fiscal year (FY) 2019 to FY 2022? Secondly, what is the cost breakdown of CC for PT referrals from FY 2020 to FY 2022?

Methods

This study was conducted by a multidisciplinary team comprised of public health, disability, rehabilitation counseling, and PT professionals. It was deemed a quality improvement project under VA guidance and followed the SQUIRE guidelines for quality improvement reporting.^24,25 The study used the VA Common Operating Platform (Palantir) to obtain individual-level CC referral data from the HealthShare Referral Manager (HSRM) database and consult data from the Computerized Patient Record System. Palantir is used to store and integrate VA data derived from the VA Corporate Data Warehouse and VHA Support Service Center. Referrals are authorizations for care to be delivered by a CC practitioner.

TR-EWI is comprised of 7 sites: VISN 2, VISN 4, VISN 8, VISN 12, VISN 15, VISN 19, and VISN 22. Each site provides telerehabilitation services with an emphasis on reaching veterans living in rural communities. We joined the referrals and consults cubes in Palantir to extract PT referrals for FY 2019 to FY 2022 for the 7 VISNs with TR-EWI sites and obtain referral-specific information and demographic characteristics. ²⁶ Data were extracted in October 2022.

The VHA Community Care Referral Dashboard (CC Dashboard) provided nonindividual level CC cost data.²⁷ The CC Dashboard provides insights into the costs of CC services for VHA enrollees by category of care, standardized episode of care, and eligibility. Data are based on nationallevel HSRM referrals that are not suspended or linked to a canceled or discontinued consult. Data were aggregated by VISN. The dashboard only includes referrals dating back to FY 2020; therefore, PT data from FY 2020 through FY 2022 for VISNs with TR-EWI sites were collected. Data were extracted in December 2022.

This study examined CC referrals, station name, eligibility types, clinical diagnoses (International Classification of Diseases, Tenth Revision codes), and demographic information in the Palantir dataset. Six eligibility criteria can qualify a veteran to receive CC.²⁸ Within clinical diagnoses, the variable of interest was the provisional diagnosis. Patient demographics included age, gender, and rurality of residence, as determined by the Rural-Urban Commuting Area system.^29,30 Rural and highly rural categories were combined for analysis. For the CC cost dataset, this study examined CC referrals, referral cost, and eligibility type.

Analysis

For the first research question, we examined referral data from FY 2019 to FY 2022 using the Palantir dataset, performed descriptive statistical analysis for all variables, and analyzed data to identify trends. Descriptive statistics were completed using IBM SPSS Statistics for Windows Version 29.0.0.0.

A qualitative analysis of provisional diagnosis data revealed what is being referred to CC for PT. A preliminary overview of provisional diagnosis data was conducted to familiarize coders with the data. We developed a coding framework to categorize diagnoses based on anatomical location, body structure, and clinical areas of interest. Data were reviewed individually and grouped into categories within the coding framework before meeting as a team to achieve group consensus on categorization. We then totaled the frequency of occurrence for provisional diagnoses within each category. Qualitative analyses were completed using Microsoft Excel.

For the second research question, the study used the CC cost dataset to examine the cost breakdown of CC PT referrals from FY 2020 to FY 2022. We calculated the number and cost of PT referrals across eligibility groups for each FY and VISN. Data were analyzed using SPSS to identify cost trends.

Results

There were 344,406 referrals to CC for PT from FY 2019 to FY 2022 for the 7 VISNs analyzed (Table 1). Of these, 22.5% were from FY 2019, 19.1% from FY 2020, 28.2% from FY 2021, and 30.3% from FY 2022. VISN 8 and VISN 22 reported the most overall PT referrals, with VISN 8 comprising 22.2% and VISN 22 comprising 18.1% of all referrals. VISN 2 reported the least overall referrals (3.7%). VISN 4 and VISN 12 had decreases in referrals over time. VISN 2 and VISN 15 had decreases in referrals from FY 2019 to FY 2021 and slight increases from FY 2021 to FY 2022. VISN 19 and VISN 22 both saw slight increases from FY 2019 to FY 2020 and substantial increases from FY 2020 to FY 2022, with FY 2022 accounting for 40.0% and 42.3% of all referrals for VISN 19 and VISN 20, respectively (Figure 1).

For FY 2019 and FY 2020, VISN 8 had the highest percentage of referrals (26.7% and 23.2%, respectively), whereas VISN 22 was among the lowest (7.3% and 11.4%, respectively). However, for FY 2021 and FY 2022, VISN 22 reported the highest percentage of referrals (23.5% and 25.3%, respectively) compared to all other VISNs. VISN 2 consistently reported the lowest percentage of referrals across all years.

There were 56 stations analyzed across the 7 VISNs (Appendix 1). Nine stations each accounted for ≥ 3.0% of the total PT referrals and only 2 stations accounted for > 5.0% of referrals. Orlando, Florida (6.0%), Philadelphia, Pennsylvania (5.2%), Tampa, Florida (4.9%), Aurora, Colorado (4.9%), and Gainesville, Florida (4.4%) reported the top 5 highest referrals, with 3 being from VISN 8 (Orlando, Tampa, Gainesville). Stations with the lowest reported referrals were all in VISN 2 in New York: The Bronx, (0%), New York Harbor (0%), Hudson Valley (0.1%) and Finger Lakes (0.2%).

Rurality

Urban stations comprised 56.2% and rural stations comprised 39.8% of PT CC referrals, while 0.2% of referrals were from insular isle US territories: Guam, American Samoa, Northern Marianas, and the Virgin Islands. The sample had missing or unknown data for 3.8% of referrals. FY 2022 had the largest difference in rural and urban referrals. Additionally, there was an overall trend of more referrals over time for rural and urban, with a large increase in rural (+40.0%) and urban (+62.7%) referrals from FY 2020 to FY 2021 and a modest increase from FY 2021 to FY 2022 (+5.2% for rural and +9.1% for urban). There was a decrease in rural (-7.0%) and urban (-3.5%) referrals from FY 2019 to FY 2020 (Figure 2).

There were differences in referrals by rurality and VISN (Table 2). VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals, whereas VISN 4, VISN 8, and VISN 22 reported more urban than rural referrals. VISN 2 reported similar numbers for both, with slightly more urban than rural referrals. When reviewing trends over time for each FY, VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals and VISN 4, VISN 8, and VISN 22 had more urban than rural referrals. In FY 2019 and FY 2020, VISN 2 reported slightly more urban than rural referrals but almost the same number of referrals in FY 2021 and FY 2022 (Appendix 2).

Demographics

The mean (SD) age was 61.2 (15.8) years (range, 20-105). Most PT CC referrals were for veterans aged 70 to 79 years (26.9%), followed by 60 to 69 years (20.7%), and 50 to 59 years (16.4%) (Appendix 3). Trends were consistent across VISNs. There was less of a difference between rural and urban referral percentages as the population aged. Veterans aged < 49 years residing in more urban areas accounted for more referrals to CC compared to their rural counterparts. This difference was less apparent in the 70 to 79 years and 80 to 89 years age brackets.

Most PT CC referrals (81.2%) were male and 14.8% were female. About 3.6% of referral data were missing sex information, and there was a smaller difference between male veterans living in rural communities and male veterans living in urban communities compared with female veterans. A total of 42.9% of male veterans resided in rural areas compared to 56.8% in urban areas; 32.7% of female veterans resided in rural areas compared to 66.9% in urban areas (Appendix 3).

Other Criteria

Of the 334,406 referrals, 114,983 (34.4%) had eligibility data, mostly from FY 2021 and FY 2022 (Table 3). Available eligibility data were likely affected by the MISSION Act and new regulations for reporting CC eligibility. Distance (33.4%) was the most common eligibility criteria, followed by timeliness of care (28.8%), and best medical interest (19.8%); 40.4% were rural and 59.5% were urban. Distance (55.4%) was most common for rural veterans, while timeliness of care (39.7%) was most common for urban veterans. For both groups, the second most common eligibility reason was best medical interest (Appendix 4).

Bone, joint, or soft tissue disorders were common diagnoses, with 25.2% located in the lower back, 14.7% in the shoulder, and 12.8% in the knee (Appendix 5). Amputations of the upper and lower limbs, fractures, cancer-related diagnoses, integumentary system disorders, thoracic and abdominal injuries and disorders, and other medical and mental health conditions each accounted for < 1% of the total diagnoses.

Costs

At time of analysis, the CC Dashboard had cost data available for 200,204 CC PT referrals from FY 2020 to FY 2022. The difference in referral numbers for the 2 datasets is likely attributed to several factors: CC cost data is exclusively from the HSRM, whereas Palantir includes other data sources; how VA cleans data pulled into Palantir; how the CC Dashboard algorithm populates data; and variances based on timing of reporting and/or if referrals are eventually canceled.

The total cost of PT CC referrals from FY 2020 to FY 2022 in selected VISNs was about $220,615,399 (Appendix 6). Appendix 7 details the methodology for determining the average standardized episode- of-care cost by VISN and how referral costs are calculated. Data show a continuous increase in total estimated cost from $46.8 million in FY 2020 to $92.1 million in FY 2022. From FY 2020 to FY 2022, aggregate costs ranged from $6,758,053 in VISN 2 to $47,209,162 in VISN 8 (Figure 3). The total referral cost for PT was highest at VISN 4 in FY 2020 ($10,447,140) and highest at VISN 22 in FY 2021 ($18,835,657) and FY 2022 ($22,962,438) (Figure 4). For referral costs from FY 2020 to FY 2022, distance accounted for $75,561,948 (34.3%), timeliness of care accounted for $60,413,496 (27.3%), and best medical interest accounted for $46,291,390 (21.0%) (Table 4).

Overall costs were primarily driven by specific VISNs within each eligibility type (Appendix 8; Figure 5). VISN 19, VISN 22, and VISN 15 accounted for the highest referral costs for distance; VISN 22, VISN 8, and VISN 19 accounted for the secondhighest referral cost, timeliness of care; and VISN 4, VISN 8, and VISN 12 accounted for the third-highest referral cost, best medical interest (Figure 5). VISN 2, VISN 4, VISN 12, VISN 15, and VISN 22 had service unavailable as an eligibility type with 1 of the top 3 associated referral costs, which was higher in cost than timeliness of care for VISN 2, VISN 4, VISN 12, and VISN 15.

Discussion

This study examines the referral of rehabilitation PT services to CC, evaluates CC costs for PT services, and analyzes utilization and cost trends among veterans within the VHA. Utilization data demonstrated a decrease in referrals from FY 2019 to FY 2020 and increases in referrals from FY 2020 to FY 2022 for most variables of interest, with cost data exhibiting similar trends. Results highlight the need for further investigation to address variations in PT referrals and costs across VISNs and eligibility reasons for CC referral.

Results demonstrated a noteworthy increase in PT CC referrals over time. The largest increase occurred from FY 2020 to FY 2021, with a smaller increase from FY 2021 to FY 2022. During this period, total enrollee numbers decreased by 3.0% across the 7 VISNs included in this analysis and by 1.6% across all VISNs, a trend that illustrates an overall decrease in enrollees as CC use increased. Results align with the implementation of the MISSION Act of 2018, which further expanded veterans’ options to use CC.^1,6,7 Results also align with the onset of the COVID-19 pandemic, which disrupted care access for many veterans, placed a larger emphasis on the use of telehealth, and increased opportunities to stay within the VA for care by rapidly shifting to telehealth and leveraging telerehabilitation investments and initiatives (such as TR-EWI).^20,31

VISN 8, VISN 19, and VISN 22, accounted for more than half of PT referrals. These VISNs had higher enrollee counts compared to the other VISNs.³² VISN 8 consistently had high levels of referrals, whereas VISN 19 and VISN 22 saw dramatic increases in FY 2021 and FY 2022. In contrast, VISN 4 and VISN 12 gradually decreased referrals during the study. VISN 2 had the lowest referral numbers during the study period, and all stations with the lowest individual referral numbers were located within VISN 2. Of the VISNs included in this study, VISN 2 had the second lowest number of enrollees (324,042).³² Reasons for increases and decreases over time could not be determined based on data collected in this study.

There were more urban than rural PT CC referrals; however, both exhibited an increase in referrals over time. This is consistent with population trends showing that most VHA patients (62.6%) and veterans (75.9%) reside in urban areas, which could explain some of the trends in this study.³³ Some VISNs have larger urban catchment areas (eg, VISN 8 and VISN 22), and some have larger rural catchment areas (eg, VISN 15 and VISN 19), which could partially explain the rural-urban differences by VISN.³² Rural-urban referral trends might also reflect existing health care delivery system deficits in rural areas and known challenges associated with accessing health care for veterans living in rural communities.^8,9

This study found larger differences in rural and urban PT CC referrals for younger age groups, with more than twice as many urban referrals in veterans aged 20 to 29 years and aged 30 to 39 years, and roughly 1.8 times as many urban referrals in veterans aged 40 to 49 years. However, there were similar numbers of rural and urban referrals in those aged 70 to 79 years and aged 80 to 89 years. These trends are consistent with data showing veterans residing in rural communities are older than their urban counterparts.^23,34 Data suggest that older veteran populations might seek PT at higher rates than younger veteran populations. Moreover, data suggest there could be differences in PT-seeking rates for younger veteran populations who reside in rural vs urban areas. Additional research is needed to understand these trends.

Distance and timeliness of care were the predominant reasons for referral among eligibility groups, which is consistent with the MISSION Act goals.^1,6,7 The most common eligibility reason for rural referrals was distance; timeliness of care was most common for urban referrals. This finding is expected, as veterans living in rural communities are farther away from VHA facilities and have longer drive times, whereas veterans living in urban communities might live closer, yet experience longer wait times due to services and/or appointment availability. Best medical interest accounted for almost 20% of referrals, which does not provide detailed insights into why those veterans were referred to CC.

The top PT diagnoses referred to CC were related to bone, joint, or soft tissue disorders of the lower back, shoulder, and knee. This suggests that musculoskeletal-related issues are prevalent among veterans seeking PT care, which is consistent with research that found > 50% of veterans receiving VHA care have musculoskeletal disorders.³⁵ The probability of experiencing musculoskeletal problems increases with age, as does the need for PT services. Amputations and fractures accounted for < 1% of CC referrals, which is consistent with the historic provision of VHA clinical specialized care to conditions prevalent among veterans. It may also represent VHA efforts to internally provide care for complex conditions requiring more extensive interdisciplinary coordination.

The total cost of referrals over time was about $221 million. VISN 8 accounted for the highest overall cost; VISN 2 had the lowest, mirroring referral utilization trends and aligning with VISN enrollee numbers. VISN 19 and VISN 22 reported large cost increases from FY 2020 to FY 2021. Total referral costs increased by $34.9 million from FY 2020 to FY 2021, which may be due to health care inflation (2.9% during FY 2019 to FY 2022), increased awareness of CC services, or increased VHA wait times.³⁶ Additionally, there were limitations in care provided across health care systems during the COVID-19 pandemic, including the VA.⁵ The increase from FY 2020 to FY 2021 may reflect a rebound from restrictions in appointments across VA, CC, and the private sector.

While the increase in total referral cost may be partly attributed to inflation, the cost effectiveness and efficiency of referring veterans to CC vs keeping veterans within VHA care is an ongoing debate.⁵ Examining and addressing cost drivers within the top eligibility types and their respective VISNs is necessary to determine resource allocation and improve quality of care. This study found that best medical interest and unavailable services accounted for 33.4% of the total cost of CC referrals, highlighting the need for policies that strengthen in-house competencies and recruit personnel to provide PT services currently unavailable within the VA.

Future Directions

The VHA should explore opportunities for in-house care, especially for services appropriate for telehealth.^18,20,37 Data indicated a smaller cost increase from FY 2021 to FY 2022 compared to the relatively large increase from FY 2020 to FY 2021. The increased telehealth usage across VHA by TR-EWI and non—TR-EWI sites within selected VISNs may have contributed to limiting the increase in CC costs. Future studies should investigate contextual factors of increased telehealth usage, which would offer guidance for implementation to optimize the integration of telehealth with PT rehabilitation provided in-house. Additionally, future studies can examine potential limitations experienced during PT telehealth visits, such as the inability to conduct hands-on assessments, challenges in viewing the quality of patient movement, ensuring patient safety in the remote environment, and the lack of PT equipment in homes for telehealth visits, and how these challenges are being addressed.^38,39 Research is also needed to understand tradeoffs of CC vs VHA care and the potential and cost benefits of keeping veterans within VHA using programs like TR-EWI.⁵ Veterans living in rural communities may especially benefit from this as expanding telehealth options can provide access to PT care that may not be readily available, enabling them to stay connected and engaged in their care.^18,40

Future studies could examine contributory factors to rising costs, such as demographic shifts, changes in PT service utilization, and policy. Researchers might also consider qualitative studies with clinicians and veterans within each VISN, which may provide insights into how local factors impact PT referral to the community.

Limitations

Due to its descriptive nature, this study can only speculate about factors influencing trends. Limitations include the inability to link the Palantir and CC Dashboard datasets for cost comparisons and potential data change over time on Palantir due to platform updates. The focus on VISNs with TREWI sites limited generalizability and this study did not compare CC PT vs VHA PT. Finally, there may have been cost drivers not identified in this study.

Conclusions

This descriptive study provides insights into the utilization and cost of PT CC referrals for selected VISNs. Cost trends underscore the financial commitment to providing PT services to veterans. Understanding what factors are driving this cost is necessary for VHA to optimally provide and manage the rehabilitation resources needed to serve veterans through traditional in-person care, telehealth, and CC options while ensuring timely, highquality care.

The Veterans Health Administration (VHA) is the largest US integrated health system, providing care to veterans through VHA and non-VHA practitioners and facilities.^1,2 Providing high-quality, timely, and veteran-centric care remains a priority for the VHA. Legislative efforts have expanded opportunities for eligible veterans to receive care in the community purchased by VHA, known as community care (CC).¹ The Veterans Access, Choice, and Accountability Act of 2014 came in response to reports of long wait times and drive times for patients.^3-5 The MISSION Act of 2018 expanded access to CC by streamlining it and broadening eligibility criteria, especially for veterans in rural communities who often experience more barriers in accessing care than veterans living in urban communities.^1,6-10 Since the implementation of the Choice and MISSION Acts, > 2.7 million veterans have received care through community practitioners within the VHA CC network.¹¹

Background

Increased access to CC could benefit veterans living in rural communities by increasing care options and circumventing challenges to accessing VHA care (ie, geographic, transportation, and distance barriers, practitioner and specialist shortages, and hospital closures). ^5,9,10,12,13 However, health care system deficits in rural areas could also limit CC effectiveness for veterans living in those communities. ³ Other challenges posed by using CC include care coordination, information sharing, care continuity, delayed payments to CC practitioners, and mixed findings regarding CC quality.^5,8,13,14 VHA practitioners are specifically trained to meet the multifaceted needs unique to veterans’ health and subculture, training CC practitioners may not receive.^5,15

CC offers services for primary care and a broad range of specialties, including rehabilitation services such as physical therapy (PT).⁶ PT is used for the effective treatment of various conditions veterans experience and promote wellbeing and independence.¹⁶ US Department of Veterans Affairs (VA) databases reveal a high prevalence of veterans receiving PT services through CC; PT is one of the most frequently used CC outpatient specialty services by veterans living in rural communities.^14,17

Telerehabitltation Enterprisewide Initiative

VHA has greatly invested in delivering care virtually, especially for veterans living in rural communities.¹⁸ In 2017, the VHA Office of Rural Health funded the Telerehabilitation Enterprise-Wide Initiative (TR-EWI) in partnership with the Physical Medicine and Rehabilitation Services national program office to increase access to specialized rehabilitation services for veterans living in rural communities by leveraging telehealth technologies.^18-21 This alternative mode of health care delivery allows clinicians to overcome access barriers by delivering rehabilitation therapies directly to veterans' homes or nearby community-based outpatient clinics. TR-EWI was conceived as a hub-and-spoke model, where rehabilitation expertise at the hub was virtually delivered to spoke sites that did not have in-house expertise. In subsequent years, the TR-EWI also evolved to provide targeted telerehabilitation programs within rural-serving community-based outpatient clinics, including PT as a predominant service.^19,20

As TR-EWI progressed—and in conjunction with the uptake of telehealth across VHA during the COVID-19 pandemic—there has been increased focus on PT telerehabilitation, especially for the 4.6 million veterans in rural communities.^18,22,23 Because health care delivery system deficits in rural areas could limit the effective use of CC, many TR-EWI sites hope to reduce their CC referrals by providing telehealth PT services to veterans who might otherwise need to be referred to CC. This strategy aligns with VHA goals of providing high-quality and timely care. To better understand opportunities for programs like TR-EWI to provide rehabilitation services for veterans and reduce care sent to the community, research that examines CC referral trends for PT over time is warranted.

This study examines CC from a rehabilitation perspective with a focus on CC referral trends for PT, specifically for Veterans Integrated Service Networks (VISNs) where TREWI sites are located. The study’s objectives were to describe rehabilitation PT services being referred to CC and examine associated CC costs for PT services. Two research questions guided the study. First, what are the utilization trends for CC PT referrals from fiscal year (FY) 2019 to FY 2022? Secondly, what is the cost breakdown of CC for PT referrals from FY 2020 to FY 2022?

Methods

This study was conducted by a multidisciplinary team comprised of public health, disability, rehabilitation counseling, and PT professionals. It was deemed a quality improvement project under VA guidance and followed the SQUIRE guidelines for quality improvement reporting.^24,25 The study used the VA Common Operating Platform (Palantir) to obtain individual-level CC referral data from the HealthShare Referral Manager (HSRM) database and consult data from the Computerized Patient Record System. Palantir is used to store and integrate VA data derived from the VA Corporate Data Warehouse and VHA Support Service Center. Referrals are authorizations for care to be delivered by a CC practitioner.

TR-EWI is comprised of 7 sites: VISN 2, VISN 4, VISN 8, VISN 12, VISN 15, VISN 19, and VISN 22. Each site provides telerehabilitation services with an emphasis on reaching veterans living in rural communities. We joined the referrals and consults cubes in Palantir to extract PT referrals for FY 2019 to FY 2022 for the 7 VISNs with TR-EWI sites and obtain referral-specific information and demographic characteristics. ²⁶ Data were extracted in October 2022.

The VHA Community Care Referral Dashboard (CC Dashboard) provided nonindividual level CC cost data.²⁷ The CC Dashboard provides insights into the costs of CC services for VHA enrollees by category of care, standardized episode of care, and eligibility. Data are based on nationallevel HSRM referrals that are not suspended or linked to a canceled or discontinued consult. Data were aggregated by VISN. The dashboard only includes referrals dating back to FY 2020; therefore, PT data from FY 2020 through FY 2022 for VISNs with TR-EWI sites were collected. Data were extracted in December 2022.

This study examined CC referrals, station name, eligibility types, clinical diagnoses (International Classification of Diseases, Tenth Revision codes), and demographic information in the Palantir dataset. Six eligibility criteria can qualify a veteran to receive CC.²⁸ Within clinical diagnoses, the variable of interest was the provisional diagnosis. Patient demographics included age, gender, and rurality of residence, as determined by the Rural-Urban Commuting Area system.^29,30 Rural and highly rural categories were combined for analysis. For the CC cost dataset, this study examined CC referrals, referral cost, and eligibility type.

Analysis

For the first research question, we examined referral data from FY 2019 to FY 2022 using the Palantir dataset, performed descriptive statistical analysis for all variables, and analyzed data to identify trends. Descriptive statistics were completed using IBM SPSS Statistics for Windows Version 29.0.0.0.

A qualitative analysis of provisional diagnosis data revealed what is being referred to CC for PT. A preliminary overview of provisional diagnosis data was conducted to familiarize coders with the data. We developed a coding framework to categorize diagnoses based on anatomical location, body structure, and clinical areas of interest. Data were reviewed individually and grouped into categories within the coding framework before meeting as a team to achieve group consensus on categorization. We then totaled the frequency of occurrence for provisional diagnoses within each category. Qualitative analyses were completed using Microsoft Excel.

For the second research question, the study used the CC cost dataset to examine the cost breakdown of CC PT referrals from FY 2020 to FY 2022. We calculated the number and cost of PT referrals across eligibility groups for each FY and VISN. Data were analyzed using SPSS to identify cost trends.

Results

There were 344,406 referrals to CC for PT from FY 2019 to FY 2022 for the 7 VISNs analyzed (Table 1). Of these, 22.5% were from FY 2019, 19.1% from FY 2020, 28.2% from FY 2021, and 30.3% from FY 2022. VISN 8 and VISN 22 reported the most overall PT referrals, with VISN 8 comprising 22.2% and VISN 22 comprising 18.1% of all referrals. VISN 2 reported the least overall referrals (3.7%). VISN 4 and VISN 12 had decreases in referrals over time. VISN 2 and VISN 15 had decreases in referrals from FY 2019 to FY 2021 and slight increases from FY 2021 to FY 2022. VISN 19 and VISN 22 both saw slight increases from FY 2019 to FY 2020 and substantial increases from FY 2020 to FY 2022, with FY 2022 accounting for 40.0% and 42.3% of all referrals for VISN 19 and VISN 20, respectively (Figure 1).

For FY 2019 and FY 2020, VISN 8 had the highest percentage of referrals (26.7% and 23.2%, respectively), whereas VISN 22 was among the lowest (7.3% and 11.4%, respectively). However, for FY 2021 and FY 2022, VISN 22 reported the highest percentage of referrals (23.5% and 25.3%, respectively) compared to all other VISNs. VISN 2 consistently reported the lowest percentage of referrals across all years.

There were 56 stations analyzed across the 7 VISNs (Appendix 1). Nine stations each accounted for ≥ 3.0% of the total PT referrals and only 2 stations accounted for > 5.0% of referrals. Orlando, Florida (6.0%), Philadelphia, Pennsylvania (5.2%), Tampa, Florida (4.9%), Aurora, Colorado (4.9%), and Gainesville, Florida (4.4%) reported the top 5 highest referrals, with 3 being from VISN 8 (Orlando, Tampa, Gainesville). Stations with the lowest reported referrals were all in VISN 2 in New York: The Bronx, (0%), New York Harbor (0%), Hudson Valley (0.1%) and Finger Lakes (0.2%).

Rurality

Urban stations comprised 56.2% and rural stations comprised 39.8% of PT CC referrals, while 0.2% of referrals were from insular isle US territories: Guam, American Samoa, Northern Marianas, and the Virgin Islands. The sample had missing or unknown data for 3.8% of referrals. FY 2022 had the largest difference in rural and urban referrals. Additionally, there was an overall trend of more referrals over time for rural and urban, with a large increase in rural (+40.0%) and urban (+62.7%) referrals from FY 2020 to FY 2021 and a modest increase from FY 2021 to FY 2022 (+5.2% for rural and +9.1% for urban). There was a decrease in rural (-7.0%) and urban (-3.5%) referrals from FY 2019 to FY 2020 (Figure 2).

There were differences in referrals by rurality and VISN (Table 2). VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals, whereas VISN 4, VISN 8, and VISN 22 reported more urban than rural referrals. VISN 2 reported similar numbers for both, with slightly more urban than rural referrals. When reviewing trends over time for each FY, VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals and VISN 4, VISN 8, and VISN 22 had more urban than rural referrals. In FY 2019 and FY 2020, VISN 2 reported slightly more urban than rural referrals but almost the same number of referrals in FY 2021 and FY 2022 (Appendix 2).

Demographics

The mean (SD) age was 61.2 (15.8) years (range, 20-105). Most PT CC referrals were for veterans aged 70 to 79 years (26.9%), followed by 60 to 69 years (20.7%), and 50 to 59 years (16.4%) (Appendix 3). Trends were consistent across VISNs. There was less of a difference between rural and urban referral percentages as the population aged. Veterans aged < 49 years residing in more urban areas accounted for more referrals to CC compared to their rural counterparts. This difference was less apparent in the 70 to 79 years and 80 to 89 years age brackets.

Most PT CC referrals (81.2%) were male and 14.8% were female. About 3.6% of referral data were missing sex information, and there was a smaller difference between male veterans living in rural communities and male veterans living in urban communities compared with female veterans. A total of 42.9% of male veterans resided in rural areas compared to 56.8% in urban areas; 32.7% of female veterans resided in rural areas compared to 66.9% in urban areas (Appendix 3).

Other Criteria

Of the 334,406 referrals, 114,983 (34.4%) had eligibility data, mostly from FY 2021 and FY 2022 (Table 3). Available eligibility data were likely affected by the MISSION Act and new regulations for reporting CC eligibility. Distance (33.4%) was the most common eligibility criteria, followed by timeliness of care (28.8%), and best medical interest (19.8%); 40.4% were rural and 59.5% were urban. Distance (55.4%) was most common for rural veterans, while timeliness of care (39.7%) was most common for urban veterans. For both groups, the second most common eligibility reason was best medical interest (Appendix 4).

Bone, joint, or soft tissue disorders were common diagnoses, with 25.2% located in the lower back, 14.7% in the shoulder, and 12.8% in the knee (Appendix 5). Amputations of the upper and lower limbs, fractures, cancer-related diagnoses, integumentary system disorders, thoracic and abdominal injuries and disorders, and other medical and mental health conditions each accounted for < 1% of the total diagnoses.

Costs

At time of analysis, the CC Dashboard had cost data available for 200,204 CC PT referrals from FY 2020 to FY 2022. The difference in referral numbers for the 2 datasets is likely attributed to several factors: CC cost data is exclusively from the HSRM, whereas Palantir includes other data sources; how VA cleans data pulled into Palantir; how the CC Dashboard algorithm populates data; and variances based on timing of reporting and/or if referrals are eventually canceled.

The total cost of PT CC referrals from FY 2020 to FY 2022 in selected VISNs was about $220,615,399 (Appendix 6). Appendix 7 details the methodology for determining the average standardized episode- of-care cost by VISN and how referral costs are calculated. Data show a continuous increase in total estimated cost from $46.8 million in FY 2020 to $92.1 million in FY 2022. From FY 2020 to FY 2022, aggregate costs ranged from $6,758,053 in VISN 2 to $47,209,162 in VISN 8 (Figure 3). The total referral cost for PT was highest at VISN 4 in FY 2020 ($10,447,140) and highest at VISN 22 in FY 2021 ($18,835,657) and FY 2022 ($22,962,438) (Figure 4). For referral costs from FY 2020 to FY 2022, distance accounted for $75,561,948 (34.3%), timeliness of care accounted for $60,413,496 (27.3%), and best medical interest accounted for $46,291,390 (21.0%) (Table 4).

Overall costs were primarily driven by specific VISNs within each eligibility type (Appendix 8; Figure 5). VISN 19, VISN 22, and VISN 15 accounted for the highest referral costs for distance; VISN 22, VISN 8, and VISN 19 accounted for the secondhighest referral cost, timeliness of care; and VISN 4, VISN 8, and VISN 12 accounted for the third-highest referral cost, best medical interest (Figure 5). VISN 2, VISN 4, VISN 12, VISN 15, and VISN 22 had service unavailable as an eligibility type with 1 of the top 3 associated referral costs, which was higher in cost than timeliness of care for VISN 2, VISN 4, VISN 12, and VISN 15.

Discussion

This study examines the referral of rehabilitation PT services to CC, evaluates CC costs for PT services, and analyzes utilization and cost trends among veterans within the VHA. Utilization data demonstrated a decrease in referrals from FY 2019 to FY 2020 and increases in referrals from FY 2020 to FY 2022 for most variables of interest, with cost data exhibiting similar trends. Results highlight the need for further investigation to address variations in PT referrals and costs across VISNs and eligibility reasons for CC referral.

Results demonstrated a noteworthy increase in PT CC referrals over time. The largest increase occurred from FY 2020 to FY 2021, with a smaller increase from FY 2021 to FY 2022. During this period, total enrollee numbers decreased by 3.0% across the 7 VISNs included in this analysis and by 1.6% across all VISNs, a trend that illustrates an overall decrease in enrollees as CC use increased. Results align with the implementation of the MISSION Act of 2018, which further expanded veterans’ options to use CC.^1,6,7 Results also align with the onset of the COVID-19 pandemic, which disrupted care access for many veterans, placed a larger emphasis on the use of telehealth, and increased opportunities to stay within the VA for care by rapidly shifting to telehealth and leveraging telerehabilitation investments and initiatives (such as TR-EWI).^20,31

VISN 8, VISN 19, and VISN 22, accounted for more than half of PT referrals. These VISNs had higher enrollee counts compared to the other VISNs.³² VISN 8 consistently had high levels of referrals, whereas VISN 19 and VISN 22 saw dramatic increases in FY 2021 and FY 2022. In contrast, VISN 4 and VISN 12 gradually decreased referrals during the study. VISN 2 had the lowest referral numbers during the study period, and all stations with the lowest individual referral numbers were located within VISN 2. Of the VISNs included in this study, VISN 2 had the second lowest number of enrollees (324,042).³² Reasons for increases and decreases over time could not be determined based on data collected in this study.

There were more urban than rural PT CC referrals; however, both exhibited an increase in referrals over time. This is consistent with population trends showing that most VHA patients (62.6%) and veterans (75.9%) reside in urban areas, which could explain some of the trends in this study.³³ Some VISNs have larger urban catchment areas (eg, VISN 8 and VISN 22), and some have larger rural catchment areas (eg, VISN 15 and VISN 19), which could partially explain the rural-urban differences by VISN.³² Rural-urban referral trends might also reflect existing health care delivery system deficits in rural areas and known challenges associated with accessing health care for veterans living in rural communities.^8,9

This study found larger differences in rural and urban PT CC referrals for younger age groups, with more than twice as many urban referrals in veterans aged 20 to 29 years and aged 30 to 39 years, and roughly 1.8 times as many urban referrals in veterans aged 40 to 49 years. However, there were similar numbers of rural and urban referrals in those aged 70 to 79 years and aged 80 to 89 years. These trends are consistent with data showing veterans residing in rural communities are older than their urban counterparts.^23,34 Data suggest that older veteran populations might seek PT at higher rates than younger veteran populations. Moreover, data suggest there could be differences in PT-seeking rates for younger veteran populations who reside in rural vs urban areas. Additional research is needed to understand these trends.

Distance and timeliness of care were the predominant reasons for referral among eligibility groups, which is consistent with the MISSION Act goals.^1,6,7 The most common eligibility reason for rural referrals was distance; timeliness of care was most common for urban referrals. This finding is expected, as veterans living in rural communities are farther away from VHA facilities and have longer drive times, whereas veterans living in urban communities might live closer, yet experience longer wait times due to services and/or appointment availability. Best medical interest accounted for almost 20% of referrals, which does not provide detailed insights into why those veterans were referred to CC.

The top PT diagnoses referred to CC were related to bone, joint, or soft tissue disorders of the lower back, shoulder, and knee. This suggests that musculoskeletal-related issues are prevalent among veterans seeking PT care, which is consistent with research that found > 50% of veterans receiving VHA care have musculoskeletal disorders.³⁵ The probability of experiencing musculoskeletal problems increases with age, as does the need for PT services. Amputations and fractures accounted for < 1% of CC referrals, which is consistent with the historic provision of VHA clinical specialized care to conditions prevalent among veterans. It may also represent VHA efforts to internally provide care for complex conditions requiring more extensive interdisciplinary coordination.

The total cost of referrals over time was about $221 million. VISN 8 accounted for the highest overall cost; VISN 2 had the lowest, mirroring referral utilization trends and aligning with VISN enrollee numbers. VISN 19 and VISN 22 reported large cost increases from FY 2020 to FY 2021. Total referral costs increased by $34.9 million from FY 2020 to FY 2021, which may be due to health care inflation (2.9% during FY 2019 to FY 2022), increased awareness of CC services, or increased VHA wait times.³⁶ Additionally, there were limitations in care provided across health care systems during the COVID-19 pandemic, including the VA.⁵ The increase from FY 2020 to FY 2021 may reflect a rebound from restrictions in appointments across VA, CC, and the private sector.

While the increase in total referral cost may be partly attributed to inflation, the cost effectiveness and efficiency of referring veterans to CC vs keeping veterans within VHA care is an ongoing debate.⁵ Examining and addressing cost drivers within the top eligibility types and their respective VISNs is necessary to determine resource allocation and improve quality of care. This study found that best medical interest and unavailable services accounted for 33.4% of the total cost of CC referrals, highlighting the need for policies that strengthen in-house competencies and recruit personnel to provide PT services currently unavailable within the VA.

Future Directions

The VHA should explore opportunities for in-house care, especially for services appropriate for telehealth.^18,20,37 Data indicated a smaller cost increase from FY 2021 to FY 2022 compared to the relatively large increase from FY 2020 to FY 2021. The increased telehealth usage across VHA by TR-EWI and non—TR-EWI sites within selected VISNs may have contributed to limiting the increase in CC costs. Future studies should investigate contextual factors of increased telehealth usage, which would offer guidance for implementation to optimize the integration of telehealth with PT rehabilitation provided in-house. Additionally, future studies can examine potential limitations experienced during PT telehealth visits, such as the inability to conduct hands-on assessments, challenges in viewing the quality of patient movement, ensuring patient safety in the remote environment, and the lack of PT equipment in homes for telehealth visits, and how these challenges are being addressed.^38,39 Research is also needed to understand tradeoffs of CC vs VHA care and the potential and cost benefits of keeping veterans within VHA using programs like TR-EWI.⁵ Veterans living in rural communities may especially benefit from this as expanding telehealth options can provide access to PT care that may not be readily available, enabling them to stay connected and engaged in their care.^18,40

Future studies could examine contributory factors to rising costs, such as demographic shifts, changes in PT service utilization, and policy. Researchers might also consider qualitative studies with clinicians and veterans within each VISN, which may provide insights into how local factors impact PT referral to the community.

Limitations

Due to its descriptive nature, this study can only speculate about factors influencing trends. Limitations include the inability to link the Palantir and CC Dashboard datasets for cost comparisons and potential data change over time on Palantir due to platform updates. The focus on VISNs with TREWI sites limited generalizability and this study did not compare CC PT vs VHA PT. Finally, there may have been cost drivers not identified in this study.

Conclusions

This descriptive study provides insights into the utilization and cost of PT CC referrals for selected VISNs. Cost trends underscore the financial commitment to providing PT services to veterans. Understanding what factors are driving this cost is necessary for VHA to optimally provide and manage the rehabilitation resources needed to serve veterans through traditional in-person care, telehealth, and CC options while ensuring timely, highquality care.

The Veterans Health Administration (VHA) is the largest US integrated health system, providing care to veterans through VHA and non-VHA practitioners and facilities.^1,2 Providing high-quality, timely, and veteran-centric care remains a priority for the VHA. Legislative efforts have expanded opportunities for eligible veterans to receive care in the community purchased by VHA, known as community care (CC).¹ The Veterans Access, Choice, and Accountability Act of 2014 came in response to reports of long wait times and drive times for patients.^3-5 The MISSION Act of 2018 expanded access to CC by streamlining it and broadening eligibility criteria, especially for veterans in rural communities who often experience more barriers in accessing care than veterans living in urban communities.^1,6-10 Since the implementation of the Choice and MISSION Acts, > 2.7 million veterans have received care through community practitioners within the VHA CC network.¹¹

Background

Increased access to CC could benefit veterans living in rural communities by increasing care options and circumventing challenges to accessing VHA care (ie, geographic, transportation, and distance barriers, practitioner and specialist shortages, and hospital closures). ^5,9,10,12,13 However, health care system deficits in rural areas could also limit CC effectiveness for veterans living in those communities. ³ Other challenges posed by using CC include care coordination, information sharing, care continuity, delayed payments to CC practitioners, and mixed findings regarding CC quality.^5,8,13,14 VHA practitioners are specifically trained to meet the multifaceted needs unique to veterans’ health and subculture, training CC practitioners may not receive.^5,15

CC offers services for primary care and a broad range of specialties, including rehabilitation services such as physical therapy (PT).⁶ PT is used for the effective treatment of various conditions veterans experience and promote wellbeing and independence.¹⁶ US Department of Veterans Affairs (VA) databases reveal a high prevalence of veterans receiving PT services through CC; PT is one of the most frequently used CC outpatient specialty services by veterans living in rural communities.^14,17

Telerehabitltation Enterprisewide Initiative

VHA has greatly invested in delivering care virtually, especially for veterans living in rural communities.¹⁸ In 2017, the VHA Office of Rural Health funded the Telerehabilitation Enterprise-Wide Initiative (TR-EWI) in partnership with the Physical Medicine and Rehabilitation Services national program office to increase access to specialized rehabilitation services for veterans living in rural communities by leveraging telehealth technologies.^18-21 This alternative mode of health care delivery allows clinicians to overcome access barriers by delivering rehabilitation therapies directly to veterans' homes or nearby community-based outpatient clinics. TR-EWI was conceived as a hub-and-spoke model, where rehabilitation expertise at the hub was virtually delivered to spoke sites that did not have in-house expertise. In subsequent years, the TR-EWI also evolved to provide targeted telerehabilitation programs within rural-serving community-based outpatient clinics, including PT as a predominant service.^19,20

As TR-EWI progressed—and in conjunction with the uptake of telehealth across VHA during the COVID-19 pandemic—there has been increased focus on PT telerehabilitation, especially for the 4.6 million veterans in rural communities.^18,22,23 Because health care delivery system deficits in rural areas could limit the effective use of CC, many TR-EWI sites hope to reduce their CC referrals by providing telehealth PT services to veterans who might otherwise need to be referred to CC. This strategy aligns with VHA goals of providing high-quality and timely care. To better understand opportunities for programs like TR-EWI to provide rehabilitation services for veterans and reduce care sent to the community, research that examines CC referral trends for PT over time is warranted.

This study examines CC from a rehabilitation perspective with a focus on CC referral trends for PT, specifically for Veterans Integrated Service Networks (VISNs) where TREWI sites are located. The study’s objectives were to describe rehabilitation PT services being referred to CC and examine associated CC costs for PT services. Two research questions guided the study. First, what are the utilization trends for CC PT referrals from fiscal year (FY) 2019 to FY 2022? Secondly, what is the cost breakdown of CC for PT referrals from FY 2020 to FY 2022?

Methods

This study was conducted by a multidisciplinary team comprised of public health, disability, rehabilitation counseling, and PT professionals. It was deemed a quality improvement project under VA guidance and followed the SQUIRE guidelines for quality improvement reporting.^24,25 The study used the VA Common Operating Platform (Palantir) to obtain individual-level CC referral data from the HealthShare Referral Manager (HSRM) database and consult data from the Computerized Patient Record System. Palantir is used to store and integrate VA data derived from the VA Corporate Data Warehouse and VHA Support Service Center. Referrals are authorizations for care to be delivered by a CC practitioner.

TR-EWI is comprised of 7 sites: VISN 2, VISN 4, VISN 8, VISN 12, VISN 15, VISN 19, and VISN 22. Each site provides telerehabilitation services with an emphasis on reaching veterans living in rural communities. We joined the referrals and consults cubes in Palantir to extract PT referrals for FY 2019 to FY 2022 for the 7 VISNs with TR-EWI sites and obtain referral-specific information and demographic characteristics. ²⁶ Data were extracted in October 2022.

The VHA Community Care Referral Dashboard (CC Dashboard) provided nonindividual level CC cost data.²⁷ The CC Dashboard provides insights into the costs of CC services for VHA enrollees by category of care, standardized episode of care, and eligibility. Data are based on nationallevel HSRM referrals that are not suspended or linked to a canceled or discontinued consult. Data were aggregated by VISN. The dashboard only includes referrals dating back to FY 2020; therefore, PT data from FY 2020 through FY 2022 for VISNs with TR-EWI sites were collected. Data were extracted in December 2022.

This study examined CC referrals, station name, eligibility types, clinical diagnoses (International Classification of Diseases, Tenth Revision codes), and demographic information in the Palantir dataset. Six eligibility criteria can qualify a veteran to receive CC.²⁸ Within clinical diagnoses, the variable of interest was the provisional diagnosis. Patient demographics included age, gender, and rurality of residence, as determined by the Rural-Urban Commuting Area system.^29,30 Rural and highly rural categories were combined for analysis. For the CC cost dataset, this study examined CC referrals, referral cost, and eligibility type.

Analysis

For the first research question, we examined referral data from FY 2019 to FY 2022 using the Palantir dataset, performed descriptive statistical analysis for all variables, and analyzed data to identify trends. Descriptive statistics were completed using IBM SPSS Statistics for Windows Version 29.0.0.0.

A qualitative analysis of provisional diagnosis data revealed what is being referred to CC for PT. A preliminary overview of provisional diagnosis data was conducted to familiarize coders with the data. We developed a coding framework to categorize diagnoses based on anatomical location, body structure, and clinical areas of interest. Data were reviewed individually and grouped into categories within the coding framework before meeting as a team to achieve group consensus on categorization. We then totaled the frequency of occurrence for provisional diagnoses within each category. Qualitative analyses were completed using Microsoft Excel.

For the second research question, the study used the CC cost dataset to examine the cost breakdown of CC PT referrals from FY 2020 to FY 2022. We calculated the number and cost of PT referrals across eligibility groups for each FY and VISN. Data were analyzed using SPSS to identify cost trends.

Results

There were 344,406 referrals to CC for PT from FY 2019 to FY 2022 for the 7 VISNs analyzed (Table 1). Of these, 22.5% were from FY 2019, 19.1% from FY 2020, 28.2% from FY 2021, and 30.3% from FY 2022. VISN 8 and VISN 22 reported the most overall PT referrals, with VISN 8 comprising 22.2% and VISN 22 comprising 18.1% of all referrals. VISN 2 reported the least overall referrals (3.7%). VISN 4 and VISN 12 had decreases in referrals over time. VISN 2 and VISN 15 had decreases in referrals from FY 2019 to FY 2021 and slight increases from FY 2021 to FY 2022. VISN 19 and VISN 22 both saw slight increases from FY 2019 to FY 2020 and substantial increases from FY 2020 to FY 2022, with FY 2022 accounting for 40.0% and 42.3% of all referrals for VISN 19 and VISN 20, respectively (Figure 1).

For FY 2019 and FY 2020, VISN 8 had the highest percentage of referrals (26.7% and 23.2%, respectively), whereas VISN 22 was among the lowest (7.3% and 11.4%, respectively). However, for FY 2021 and FY 2022, VISN 22 reported the highest percentage of referrals (23.5% and 25.3%, respectively) compared to all other VISNs. VISN 2 consistently reported the lowest percentage of referrals across all years.

There were 56 stations analyzed across the 7 VISNs (Appendix 1). Nine stations each accounted for ≥ 3.0% of the total PT referrals and only 2 stations accounted for > 5.0% of referrals. Orlando, Florida (6.0%), Philadelphia, Pennsylvania (5.2%), Tampa, Florida (4.9%), Aurora, Colorado (4.9%), and Gainesville, Florida (4.4%) reported the top 5 highest referrals, with 3 being from VISN 8 (Orlando, Tampa, Gainesville). Stations with the lowest reported referrals were all in VISN 2 in New York: The Bronx, (0%), New York Harbor (0%), Hudson Valley (0.1%) and Finger Lakes (0.2%).

Rurality

Urban stations comprised 56.2% and rural stations comprised 39.8% of PT CC referrals, while 0.2% of referrals were from insular isle US territories: Guam, American Samoa, Northern Marianas, and the Virgin Islands. The sample had missing or unknown data for 3.8% of referrals. FY 2022 had the largest difference in rural and urban referrals. Additionally, there was an overall trend of more referrals over time for rural and urban, with a large increase in rural (+40.0%) and urban (+62.7%) referrals from FY 2020 to FY 2021 and a modest increase from FY 2021 to FY 2022 (+5.2% for rural and +9.1% for urban). There was a decrease in rural (-7.0%) and urban (-3.5%) referrals from FY 2019 to FY 2020 (Figure 2).

There were differences in referrals by rurality and VISN (Table 2). VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals, whereas VISN 4, VISN 8, and VISN 22 reported more urban than rural referrals. VISN 2 reported similar numbers for both, with slightly more urban than rural referrals. When reviewing trends over time for each FY, VISN 12, VISN 15, and VISN 19 reported more rural than urban referrals and VISN 4, VISN 8, and VISN 22 had more urban than rural referrals. In FY 2019 and FY 2020, VISN 2 reported slightly more urban than rural referrals but almost the same number of referrals in FY 2021 and FY 2022 (Appendix 2).

Demographics

The mean (SD) age was 61.2 (15.8) years (range, 20-105). Most PT CC referrals were for veterans aged 70 to 79 years (26.9%), followed by 60 to 69 years (20.7%), and 50 to 59 years (16.4%) (Appendix 3). Trends were consistent across VISNs. There was less of a difference between rural and urban referral percentages as the population aged. Veterans aged < 49 years residing in more urban areas accounted for more referrals to CC compared to their rural counterparts. This difference was less apparent in the 70 to 79 years and 80 to 89 years age brackets.

Most PT CC referrals (81.2%) were male and 14.8% were female. About 3.6% of referral data were missing sex information, and there was a smaller difference between male veterans living in rural communities and male veterans living in urban communities compared with female veterans. A total of 42.9% of male veterans resided in rural areas compared to 56.8% in urban areas; 32.7% of female veterans resided in rural areas compared to 66.9% in urban areas (Appendix 3).

Other Criteria

Of the 334,406 referrals, 114,983 (34.4%) had eligibility data, mostly from FY 2021 and FY 2022 (Table 3). Available eligibility data were likely affected by the MISSION Act and new regulations for reporting CC eligibility. Distance (33.4%) was the most common eligibility criteria, followed by timeliness of care (28.8%), and best medical interest (19.8%); 40.4% were rural and 59.5% were urban. Distance (55.4%) was most common for rural veterans, while timeliness of care (39.7%) was most common for urban veterans. For both groups, the second most common eligibility reason was best medical interest (Appendix 4).

Bone, joint, or soft tissue disorders were common diagnoses, with 25.2% located in the lower back, 14.7% in the shoulder, and 12.8% in the knee (Appendix 5). Amputations of the upper and lower limbs, fractures, cancer-related diagnoses, integumentary system disorders, thoracic and abdominal injuries and disorders, and other medical and mental health conditions each accounted for < 1% of the total diagnoses.

Costs

At time of analysis, the CC Dashboard had cost data available for 200,204 CC PT referrals from FY 2020 to FY 2022. The difference in referral numbers for the 2 datasets is likely attributed to several factors: CC cost data is exclusively from the HSRM, whereas Palantir includes other data sources; how VA cleans data pulled into Palantir; how the CC Dashboard algorithm populates data; and variances based on timing of reporting and/or if referrals are eventually canceled.

The total cost of PT CC referrals from FY 2020 to FY 2022 in selected VISNs was about $220,615,399 (Appendix 6). Appendix 7 details the methodology for determining the average standardized episode- of-care cost by VISN and how referral costs are calculated. Data show a continuous increase in total estimated cost from $46.8 million in FY 2020 to $92.1 million in FY 2022. From FY 2020 to FY 2022, aggregate costs ranged from $6,758,053 in VISN 2 to $47,209,162 in VISN 8 (Figure 3). The total referral cost for PT was highest at VISN 4 in FY 2020 ($10,447,140) and highest at VISN 22 in FY 2021 ($18,835,657) and FY 2022 ($22,962,438) (Figure 4). For referral costs from FY 2020 to FY 2022, distance accounted for $75,561,948 (34.3%), timeliness of care accounted for $60,413,496 (27.3%), and best medical interest accounted for $46,291,390 (21.0%) (Table 4).

Overall costs were primarily driven by specific VISNs within each eligibility type (Appendix 8; Figure 5). VISN 19, VISN 22, and VISN 15 accounted for the highest referral costs for distance; VISN 22, VISN 8, and VISN 19 accounted for the secondhighest referral cost, timeliness of care; and VISN 4, VISN 8, and VISN 12 accounted for the third-highest referral cost, best medical interest (Figure 5). VISN 2, VISN 4, VISN 12, VISN 15, and VISN 22 had service unavailable as an eligibility type with 1 of the top 3 associated referral costs, which was higher in cost than timeliness of care for VISN 2, VISN 4, VISN 12, and VISN 15.

Discussion

This study examines the referral of rehabilitation PT services to CC, evaluates CC costs for PT services, and analyzes utilization and cost trends among veterans within the VHA. Utilization data demonstrated a decrease in referrals from FY 2019 to FY 2020 and increases in referrals from FY 2020 to FY 2022 for most variables of interest, with cost data exhibiting similar trends. Results highlight the need for further investigation to address variations in PT referrals and costs across VISNs and eligibility reasons for CC referral.

Results demonstrated a noteworthy increase in PT CC referrals over time. The largest increase occurred from FY 2020 to FY 2021, with a smaller increase from FY 2021 to FY 2022. During this period, total enrollee numbers decreased by 3.0% across the 7 VISNs included in this analysis and by 1.6% across all VISNs, a trend that illustrates an overall decrease in enrollees as CC use increased. Results align with the implementation of the MISSION Act of 2018, which further expanded veterans’ options to use CC.^1,6,7 Results also align with the onset of the COVID-19 pandemic, which disrupted care access for many veterans, placed a larger emphasis on the use of telehealth, and increased opportunities to stay within the VA for care by rapidly shifting to telehealth and leveraging telerehabilitation investments and initiatives (such as TR-EWI).^20,31

VISN 8, VISN 19, and VISN 22, accounted for more than half of PT referrals. These VISNs had higher enrollee counts compared to the other VISNs.³² VISN 8 consistently had high levels of referrals, whereas VISN 19 and VISN 22 saw dramatic increases in FY 2021 and FY 2022. In contrast, VISN 4 and VISN 12 gradually decreased referrals during the study. VISN 2 had the lowest referral numbers during the study period, and all stations with the lowest individual referral numbers were located within VISN 2. Of the VISNs included in this study, VISN 2 had the second lowest number of enrollees (324,042).³² Reasons for increases and decreases over time could not be determined based on data collected in this study.

There were more urban than rural PT CC referrals; however, both exhibited an increase in referrals over time. This is consistent with population trends showing that most VHA patients (62.6%) and veterans (75.9%) reside in urban areas, which could explain some of the trends in this study.³³ Some VISNs have larger urban catchment areas (eg, VISN 8 and VISN 22), and some have larger rural catchment areas (eg, VISN 15 and VISN 19), which could partially explain the rural-urban differences by VISN.³² Rural-urban referral trends might also reflect existing health care delivery system deficits in rural areas and known challenges associated with accessing health care for veterans living in rural communities.^8,9

This study found larger differences in rural and urban PT CC referrals for younger age groups, with more than twice as many urban referrals in veterans aged 20 to 29 years and aged 30 to 39 years, and roughly 1.8 times as many urban referrals in veterans aged 40 to 49 years. However, there were similar numbers of rural and urban referrals in those aged 70 to 79 years and aged 80 to 89 years. These trends are consistent with data showing veterans residing in rural communities are older than their urban counterparts.^23,34 Data suggest that older veteran populations might seek PT at higher rates than younger veteran populations. Moreover, data suggest there could be differences in PT-seeking rates for younger veteran populations who reside in rural vs urban areas. Additional research is needed to understand these trends.

Distance and timeliness of care were the predominant reasons for referral among eligibility groups, which is consistent with the MISSION Act goals.^1,6,7 The most common eligibility reason for rural referrals was distance; timeliness of care was most common for urban referrals. This finding is expected, as veterans living in rural communities are farther away from VHA facilities and have longer drive times, whereas veterans living in urban communities might live closer, yet experience longer wait times due to services and/or appointment availability. Best medical interest accounted for almost 20% of referrals, which does not provide detailed insights into why those veterans were referred to CC.

The top PT diagnoses referred to CC were related to bone, joint, or soft tissue disorders of the lower back, shoulder, and knee. This suggests that musculoskeletal-related issues are prevalent among veterans seeking PT care, which is consistent with research that found > 50% of veterans receiving VHA care have musculoskeletal disorders.³⁵ The probability of experiencing musculoskeletal problems increases with age, as does the need for PT services. Amputations and fractures accounted for < 1% of CC referrals, which is consistent with the historic provision of VHA clinical specialized care to conditions prevalent among veterans. It may also represent VHA efforts to internally provide care for complex conditions requiring more extensive interdisciplinary coordination.

The total cost of referrals over time was about $221 million. VISN 8 accounted for the highest overall cost; VISN 2 had the lowest, mirroring referral utilization trends and aligning with VISN enrollee numbers. VISN 19 and VISN 22 reported large cost increases from FY 2020 to FY 2021. Total referral costs increased by $34.9 million from FY 2020 to FY 2021, which may be due to health care inflation (2.9% during FY 2019 to FY 2022), increased awareness of CC services, or increased VHA wait times.³⁶ Additionally, there were limitations in care provided across health care systems during the COVID-19 pandemic, including the VA.⁵ The increase from FY 2020 to FY 2021 may reflect a rebound from restrictions in appointments across VA, CC, and the private sector.

While the increase in total referral cost may be partly attributed to inflation, the cost effectiveness and efficiency of referring veterans to CC vs keeping veterans within VHA care is an ongoing debate.⁵ Examining and addressing cost drivers within the top eligibility types and their respective VISNs is necessary to determine resource allocation and improve quality of care. This study found that best medical interest and unavailable services accounted for 33.4% of the total cost of CC referrals, highlighting the need for policies that strengthen in-house competencies and recruit personnel to provide PT services currently unavailable within the VA.

Future Directions

The VHA should explore opportunities for in-house care, especially for services appropriate for telehealth.^18,20,37 Data indicated a smaller cost increase from FY 2021 to FY 2022 compared to the relatively large increase from FY 2020 to FY 2021. The increased telehealth usage across VHA by TR-EWI and non—TR-EWI sites within selected VISNs may have contributed to limiting the increase in CC costs. Future studies should investigate contextual factors of increased telehealth usage, which would offer guidance for implementation to optimize the integration of telehealth with PT rehabilitation provided in-house. Additionally, future studies can examine potential limitations experienced during PT telehealth visits, such as the inability to conduct hands-on assessments, challenges in viewing the quality of patient movement, ensuring patient safety in the remote environment, and the lack of PT equipment in homes for telehealth visits, and how these challenges are being addressed.^38,39 Research is also needed to understand tradeoffs of CC vs VHA care and the potential and cost benefits of keeping veterans within VHA using programs like TR-EWI.⁵ Veterans living in rural communities may especially benefit from this as expanding telehealth options can provide access to PT care that may not be readily available, enabling them to stay connected and engaged in their care.^18,40

Future studies could examine contributory factors to rising costs, such as demographic shifts, changes in PT service utilization, and policy. Researchers might also consider qualitative studies with clinicians and veterans within each VISN, which may provide insights into how local factors impact PT referral to the community.

Limitations

Due to its descriptive nature, this study can only speculate about factors influencing trends. Limitations include the inability to link the Palantir and CC Dashboard datasets for cost comparisons and potential data change over time on Palantir due to platform updates. The focus on VISNs with TREWI sites limited generalizability and this study did not compare CC PT vs VHA PT. Finally, there may have been cost drivers not identified in this study.

Conclusions

This descriptive study provides insights into the utilization and cost of PT CC referrals for selected VISNs. Cost trends underscore the financial commitment to providing PT services to veterans. Understanding what factors are driving this cost is necessary for VHA to optimally provide and manage the rehabilitation resources needed to serve veterans through traditional in-person care, telehealth, and CC options while ensuring timely, highquality care.

The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.

The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.

The US Department of Veterans Affairs (VA) has been integral in resident training. Resident surgical training requires a balance of supervision and autonomy, along with procedure repetition and appropriate feedback.^1-3 Non-VA research has found that resident participation across various otolaryngology procedures, including thyroidectomy, neck dissection, and laryngectomy, does not increase patient morbidity.^4-7 However, resident involvement in private and academic settings that included nonhead and neck procedures was linked to increased operative time and reduced productivity, as determined by work relative value units (wRVUs).^7-13 This has also been identified in other specialties, including general surgery, orthopedics, and ophthalmology.^14-16

Unlike the private sector, surgeon compensation at the VA is not as closely linked to operative productivity, offering a unique setting for resident training. While VA integration in otolaryngology residency programs increases resident case numbers, particularly in head and neck cases, the impact on VA patient outcomes and productivity is unknown.¹⁷ The use of larynxpreserving treatment modalities for laryngeal cancer has led to a decline in the number of total laryngectomies performed, which could potentially impact resident operative training for laryngectomies.^18-20

This study sought to determine the impact of resident participation on operative time, wRVUs, and patient outcomes in veterans who underwent a total laryngectomy. This study was reviewed and approved by the MedStar Georgetown University Hospital Institutional Review Board and Research and Development Committee (#1595672).

Methods

A retrospective cohort of veterans nationwide who underwent total laryngectomy between 2001 and 2021, with or without neck dissection, was identified from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Data were extracted via the VA Informatics and Computing Infrastructure and patients were included based on Current Procedural Terminology codes for total laryngectomy, with or without neck dissection (31320, 31360, 31365). Laryngopharyngectomies, partial laryngectomies, and minimally invasive laryngectomies were excluded. VASQIP nurse data managers reviewed patient data for operative data, postoperative outcomes (including 30- day morbidity and mortality), and preoperative risk factors (Appendix).²¹

The VASQIP data provide the highest resident or postgraduate year (PGY) per surgery. PGY 1, 2, and 3 were considered junior residents and PGY ≥4, surgical fellows, and individuals who took research years during residency were considered senior residents. Cases performed by attending physicians alone were compared with those involving junior or senior residents.

Patient demographic data included age, body mass index, smoking and alcohol use, weight loss, and functional status. Consumption of any tobacco products within 12 months of surgery was considered tobacco use. Drinking on average ≥2 alcoholic beverages daily was considered alcohol use. Weight loss was defined as a 10% reduction in body weight within the 6 months before surgery, excluding patients enrolled in a weight loss program. Functional status was categorized as independent, partially dependent, totally dependent, and unknown.

Primary outcomes included operative time, wRVUs generated, and wRVUs generated per hour of operative time. Postoperative complications were recorded both as a continuous variable and as a binary variable for presence or absence of a complication. Additional outcome variables included length of postoperative hospital stay, return to the operating room (OR), and death within 30 days of surgery.

Statistical Analysis

Data were summarized using frequency and percentage for categorical variables and median with IQR for continuous variables. Data were also summarized based on resident involvement in the surgery and the PGY level of the residents involved. The occurrence of total laryngectomy, rate of complications, and patient return to the OR were summarized by year.

Univariate associations between resident involvement and surgical outcomes were analyzed using the Kruskal-Wallis test for continuous variables and the ÷2 test for categorical variables. A Fisher exact test was used when the cell count in the contingency table was < 5. The univariate associations between surgical outcomes and demographic/preoperative variables were examined using 2-sided Wilcoxon ranksum tests or Kruskal-Wallis tests between continuous variables and categorical variables, X² or Fisher exact test between 2 categorical variables, and 2-sided Spearman correlation test between 2 continuous variables. A false-discovery rate approach was used for simultaneous posthoc tests to determine the adjusted P values for wRVUs generated/operative time for attending physicians alone vs with junior residents and for attending physicians alone vs with senior residents. Models were used to evaluate the effects of resident involvement on surgical outcomes, adjusting for variables that showed significant univariate associations. Linear regression models were used for operative time, wRVUs generated, wRVUs generated/operative time, and length of postoperative stay. A logistic regression model was used for death within 30 days. Models were not built for postoperative complications or patient return to the OR, as these were only statistically significantly associated with the patient’s preoperative functional status. A finding was considered significant if P < .05. All analyses were performed using statistical software RStudio Version 2023.03.0.

Results

Between 2001 and 2021, 1857 patients who underwent total laryngectomy were identified from the VASQIP database nationwide. Most of the total laryngectomies were staffed by an attending physician with a senior resident (n = 1190, 64%), 446 (24%) were conducted by the attending physician alone, and 221 (12%) by an attending physician with a junior resident (Table 1). The mean operating time for an attending physician alone was 378 minutes, 384 minutes for an attending physician with a senior resident, and 432 minutes for an attending physician with a junior resident (Table 2). There was a statistically significant increase in operating time for laryngectomies with resident participation compared to attending physicians operating alone (P < .001).

When the wRVUs generated/operative time was analyzed, there was a statistically significant difference between comparison groups. Total laryngectomies performed by attending physicians alone had the highest wRVUs generated/operative time (5.5), followed by laryngectomies performed by attending physicians with senior residents and laryngectomies performed by attending physicians with junior residents (5.2 and 4.8, respectively; P = .002). Table 3 describes adjusted P values for wRVUs generated/ operative time for total laryngectomies performed by attending physicians alone vs with junior residents (P = .003) and for attending physicians alone vs with senior residents (P = .02). Resident participation in total laryngectomies did not significantly impact the development or number of postoperative complications or the rate of return to the OR.

The number of laryngectomies performed in a single fiscal year peaked in 2010 at 170 cases (Figure 1). Between 2001 and 2021, the mean rates of postoperative complications (21.3%) and patient return to the OR (14.6%) did not significantly change. Resident participation in total laryngectomies also peaked in 2010 at 89.0% but has significantly declined, falling to a low of 43.6% in 2021 (Figure 2). From 2001 to 2011, the mean resident participation rate in total laryngectomies was 80.6%, compared with 68.3% from 2012 to 2021 (P < .001).

The effect of various demographic and preoperative characteristics on surgical outcomes was also analyzed. A linear regression model accounted for each variable significantly associated with operative time. On multivariable analysis, when all other variables were held constant, Table 4 shows the estimated change in operative time based on certain criteria. For instance, the operative time for attendings with junior residents surgeries was 40 minutes longer (95% CI, 16 to 64) than that of attending alone surgeries (P = .001). Furthermore, operative time decreased by 1.1 minutes (95% CI, 0.30 to 2.04) for each 1-year increase in patient age (P = .009).

A multivariable logistic regression model evaluated the effect of resident involvement on 30-day mortality rates. Senior resident involvement (P = .02), partially dependent functional status (P = .01), totally dependent functional status (P < .001), and advanced age (P = .02) all were significantly associated with 30-day mortality (Table 5). When other variables remained constant, the odds of death for totally dependent patients were 10.4 times higher than that of patients with independent functional status. Thus, totally dependent functional status appeared to have a greater impact on this outcome than resident participation. The linear regression model for postoperative length of stay demonstrated that senior resident involvement (P = .04), functional status (partially dependent vs independent P < .001), and age (P = .03) were significantly associated with prolonged length of stay.

Discussion

Otolaryngology residency training is designed to educate future otolaryngologists through hands-on learning, adequate feedback, and supervision.¹ Although this exposure is paramount for resident education, balancing appropriate supervision and autonomy while mitigating patient risk has been difficult. Numerous non-VA studies have reviewed the impact of resident participation on patient outcomes in various specialties, ranging from a single institution to the National Surgical Quality Improvement Program (NSQIP).^4,5,7,22 This study is the first to describe the nationwide impact of resident participation on outcomes in veterans undergoing total laryngectomy.

This study found that resident participation increases operative time and decreases wRVUs generated/operative time without impacting complication rates or patient return to the OR. This reinforces the notion that under close supervision, resident participation does not negatively impact patient outcomes. Resident operative training requires time and dedication by the attending physician and surgical team, thereby increasing operative time. Because VA physician compensation is not linked with productivity as closely as it is in other private and academic settings, surgeons can dedicate more time to operative teaching. This study found that a total laryngectomy involving a junior resident took about 45 minutes longer than an attending physician working alone.

As expected, with longer operative times, the wRVUs generated/operative time ratio was lower in cases with resident participation. Even though resident participation leads to lower OR efficiency, their participation may not significantly impact ancillary costs.²³ However, a recent study from NSQIP found an opportunity cost of $60.44 per hour for surgeons operating with a resident in head and neck cases.¹³

Postoperative complications and mortality are key measures of surgical outcomes in addition to operative time and efficiency. This study found that neither junior nor senior resident participation significantly increased complication rates or patient return to the OR. Despite declining resident involvement and the number of total laryngectomy surgeries in the VA, the complication rate has remained steady. The 30-day mortality rate was significantly higher in cases involving senior residents compared to cases with attending physicians alone. This could be a result of senior resident participation in more challenging cases, such as laryngectomies performed as salvage surgery following radiation. Residents are more often involved in cases with greater complexity at teaching institutions.^24-26 Therefore, the higher mortality seen among laryngectomies with senior resident involvement is likely due to the higher complexity of those cases.

The proportion of resident involvement in laryngectomies at VA medical centers has been decreasing over time. Due to the single payer nature of the VA health care system and the number of complex and comorbid patients, the VA offers an invaluable space for resident education in the OR. The fact that less than half of laryngectomies in 2021 involved resident participation is noteworthy for residency training programs. As wRVU compensation models evolve, VA attending surgeons may face less pressure to move the case along, leading to a high potential for operative teaching. Therefore, complex cases, such as laryngectomies, are often ideal for resident participation in the VA.

The steady decline in total laryngectomies at the VA parallels the recent decrease seen in non-VA settings.²⁰ This is due in part to the use of larynx-preserving treatment modalities for laryngeal cancer as well as decreases in the incidence of laryngeal cancer due to population level changes in smoking behaviors. ^18,19 Although a laryngectomy is not a key indicator case as determined by the Accreditation Council for Graduate Medical Education, it is important for otolaryngology residents to be exposed to these cases and have a thorough understanding of the operative technique.²⁷ Total laryngectomy was selected for this study because it is a complex and time-consuming surgery with somewhat standardized surgical steps. Unlike microvascular surgery that is very rarely performed by an attending physician alone, laryngectomies can be performed by attending physicians alone or with a resident.²⁸

Limitations

Since this was a retrospective study, it was susceptible to errors in data entry and data extraction from the VASQIP database. Another limitation is the lack of preoperative treatment data on tumor stage and prior nonoperative treatment. For example, a salvage laryngectomy after treatment with radiation and/or chemoradiation is a higher risk procedure than an upfront laryngectomy. Senior resident involvement may be more common in patients undergoing salvage laryngectomy due to the high risk of postoperative fistula and other complications. This may have contributed to the association identified between senior resident participation and 30-day mortality.

Since we could not account for residents who took research years or were fellows, a senior resident may have been mislabeled as a junior resident or vice versa. However, because most research years occur following the third year of residency. We are confident that PGY-1, PGY-2, and PGY-3 is likely to capture junior residents. Other factors, such as coattending surgeon cases, medical student assistance, and fellow involvement may have also impacted the results of this study.

Conclusions

This study is the first to investigate the impact of resident participation on operative time, wRVUs generated, and complication rates in head and neck surgery at VA medical centers. It found that resident participation in total laryngectomies among veterans increased operative time and reduced wRVUs generated per hour but did not impact complication rate or patient return to the OR. The VA offers a unique and invaluable space for resident education and operative training, and the recent decline in resident participation among laryngectomies is important for residency programs to acknowledge and potentially address moving forward.

In contrast to oral cavity resections which can vary from partial glossectomies to composite resections, laryngectomy represents a homogenous procedure from which to draw meaningful conclusions about complication rates, operative time, and outcome. Future directions should include studying other types of head and neck surgery in the VA to determine whether the impact of resident participation mirrors the findings of this study.