A descriptive analysis of medical health services utilization of Veterans living in Ontario: a retrospective cohort study using administrative healthcare data

Health services utilization by Veterans may be different than the general population. Occupational conditions, requirements and injuries likely determine differences in healthcare needs among Veterans. In Canada, members of the Canadian Armed Forces (CAF) transition from a federally-run and highly specialized healthcare system, the Canadian Forces Health Services (CFHS) to a provincial, publicly-funded healthcare system at the end of their career. Until April 2013, members of the Royal Canadian Mounted Police (RCMP) used the provincial healthcare system in Canada while serving; however they were considered non-provincial residents and their health services use was billed to the federal system [1–3]. Veterans of the CAF and the RCMP may be supported by additional health benefits from Veterans Affairs Canada (VAC); however, only 35 % of Regular Forces Veterans report receiving benefits [4]. Approximately one third of VAC clients are war service Veterans, one third are surviving families of Veterans, 27 % are CAF members or Veterans, and 3 % are RCMP [5]. The transition to civilian life is already a difficult adjustment for approximately 25 % of Veterans [6] and this difficulty may be exacerbated by challenges inherent in navigating appropriate health services within the provincial system after transition from the federal system.

The unique exposures of an individual’s career in the CAF or RCMP likely influence subsequent health care needs and patterns of health services use as a civilian. A study of mortality occurring within the Canadian military concluded that almost 50 % of deaths were caused by medical disease, with 35 % resulting from preventable or modifiable behaviours such as smoking and alcohol use [7]. Studies from VAC report that 17 % of Veterans who served full time in the military reported being a daily smoker, and 25 % met criteria for being a heavy drinker [4]. The Life After Service Studies from VAC concluded that Canadian Veterans have a higher prevalence of many self-reported chronic health conditions than the general population [4]. Over 70 % of Regular Forces Veterans reported having one or more chronic physical condition and 24 % reported a chronic mental health condition [4]. However, patterns of health services utilization related to these high rates of medical problems in Canadian Veterans have not been previously described or been available for study. This information is needed to understand the transition to civilian life that includes accessing healthcare in a civilian health care system, and to plan future health services use.

Longitudinal health services utilization data following Canadian Veterans from the time that they are released has not been reported until now. Data collected by VAC through the Life After Service surveys have been the only source of information on health services utilization of Veterans in Canada [4, 6]. This information is limited because it is cross-sectional and only provides details about private health insurance (prescription, dental, vision) and access to a regular family doctor (self-reported rather than actual claims data) [4].

Our group has recently reported on the development of a resource of longitudinal data to study Veterans residing in Ontario [8]. This resource utilized Ontario’s administrative healthcare databases and has incredible research potential to augment existing survey data collected by Veterans Affairs Canada (VAC) [4, 6]. The purpose of this study is to describe the non-mental health services utilization of Veterans in Ontario over time, stratified by age at release.

The cohort is comprised of 23, 818 CAF or RCMP Veterans who lived in Ontario and provided documentation of their service history when applying for an OHIP card (n excluded = 3,955) (Fig. 1). The average follow-up time was 9.33 years (SD 6.13). The average age of the cohort on entry into the Ontario healthcare system was 53.6 years (SD 2.53) and approximately 15 % of Veterans were female. The majority of Veterans resided in areas with the top three highest median community income quintiles and in an urban area, specifically in the the South East and Champlain Local Health Integration Networks (LHINs), two of the health service regions of Ontario.

Following entry into the provincial healthcare system, 82.6 % (CI 82.1-83.1) of Veterans saw their family physician at least once over the first five years following release, 40.8 % (CI 40.2–41.5) went to the emergency department in that same time period and 9.9 % (9.5-10.3) were hospitalized for non-mental health related complaints (Fig. 2). Over the duration of the study, the proportion visiting a family doctor remained stable, while the proportion visiting the emergency department decreased and the proportion hospitalized increased slightly. The average number of physician and inpatient health visits accessed during each time interval is reported in Table 1.

		Time intervals following entry into the provincial healthcare system
Non-mental health services utilization		0-5 years	5-10 years	10-15 years	15-20 years
		(N = 23,818)	(N = 15,900)	(N = 10,688)	(N = 6,191)
Healthcare Encounters
Family Doctor Visit	Mean (SD)	11.81 (13.24)	13.32 (13.91)	13.60 (14.40)	10.45 (11.29)
	Median (IQR)	8 (4–15)	10 (4–18)	10 (5–18)	7 (3–14)
	Mean (SD)	6.89 (8.78)	7.98 (10.51)	9.13 (10.77)	8.63 (10.12)
	Median (IQR)	4 (2–9)	5 (2–10)	6 (2–12)	5 (2–11)
Emergency Room Visits	Mean (SD)	3.17 (4.58)	2.65 (3.10)	2.69 (3.33)	2.33 (2.31)
	Median (IQR)	2 (1–4)	2 (1–3)	2 (1–3)	2 (1–3)
Hospitalizations	Mean (SD)	1.58 (1.28)	1.61 (1.41)	1.64 (1.54)	1.65 (1.33)
	Median (IQR)	1 (1–2)	1 (1–2)	1 (1–2)	1 (1–2)
Cumulative hospital stay (days)	Mean (SD)	6.93 (13.78)	8.05 (15.58)	8.13 (14.01)	10.63 (18.59)
	Median (IQR)	3 (2–7)	4 (2–8)	4 (2–8)	5 (2–10)

Stratifying health services utilization by age of the Veteran at entry into the provincial healthcare system revealed differences in service use and intensity (Additional file 1: Table S1 and Additional file 2: Table S2). In the first five years after entry into the healthcare system, a larger proportion of Veterans aged 50 and older visited a family doctor than Veterans under age 30 (Fig. 3a). This pattern persisted over the time intervals studied. Similarly, in the fifteen years following entry into the system, Veterans who were under 30 when they released, who visited a family doctor went on average 8 times every five years, while Veterans who were 50 and older averaged 12 to 16 visits per person over the same time intervals (Fig. 3b). Again, the average number of visits was highest in the group of Veterans who were 50 and older at the time of release.

A larger proportion of Veterans in the 50 or older age category (68.6 %) saw a non-mental health specialist in the first five years following release compared to the youngest age category (51.6) (Fig. 4a). This pattern persisted and differences in use increased over time as the cohort aged. The average number of visits per Veteran to a non-mental health specialist was lowest in the first five years following release, and increased over time (Fig. 4b).

Younger Veterans were higher users of emergency departments in the first five years following entry into the provincial healthcare system than older Veterans (Fig. 5a). Almost 61.6 % of Veterans who were under 30 at the time of entry into the system visited the emergency department, compared to 46.6 % of Veterans aged 30–39, 36.7 % of Veterans aged 40–49, and 28.7 % of Veterans 50 and older. The average number of visits per Veteran who used the emergency department was also highest in the younger Veterans (aged 30 or younger) in the first five years following release from service, although this difference attenuated at subsequent time points (Fig. 5b).

Patterns of hospitalization across the time intervals differed according to the age of the Veteran at entry into the provincial healthcare system (Additional file 1: Table S1 and Additional file 2: Table S2). Hospitalization rates decreased over time for Veterans in the two youngest age categories, and increased over time for the two older age categories. Veterans in the oldest age category had the highest rates of inpatient admissions. Among individuals who were hospitalized over the study period, older Veterans had longer cumulative lengths of stay within each time interval than younger Veterans (Additional file 1: Table S1 and Additional file 2: Table S2). The number of hospital days per time interval appeared relatively stable until the 15–20 years from entry into the provincial system. This may be due to the smaller sample sizes within each category for that period of follow-up, as the median values remained relatively unchanged.

This study provides the first general overview of Veteran non-mental health services utilization within the Ontario public healthcare system. Veterans residing in Ontario are steady and consistent users of the provincial healthcare system from the time they enter the system following release from service. Independent of age, a high proportion of Veterans visited a family doctor in the first five years following entry into the provincial healthcare system. Patterns of non-mental health services utilization in Canadian Veterans appear to change over time, depend on the service being provided, and differ according to the age of the Veteran at entry into the provincial healthcare system. While there is high engagement of non-mental health primary care across all age categories, there is a large difference in the use of emergency department visits between younger and older Veterans. This may suggest that either young Veterans have more non-mental health medical crises despite primary care physician involvement, or that they are not getting enough healthcare from regular primary care physician engagement. Overall, non-mental healthcare services are time-dependent and requirements for some healthcare services differ between younger and older Veterans.

Family physicians are considered a key point of contact within the Canadian public healthcare system. The Veteran File series published in the Canadian Family Physician in collaboration with Veterans Affairs Canada documents the important role primary healthcare clinicians play in addressing the unique needs of Canadian Veterans living in Ontario [13]. In our study, we saw that 83 % of Veterans in Ontario visited a family physician at least once in the first five years following release (ranging from 79 % in Veterans under 30 years old to 85 % in older Veterans older than 50 years old) and observed these rates are relatively stable over time. The ICES primary care atlas reported only 45 % of individuals aged 20–39 and 39 % in those age 40 and older visited a primary care doctor annually [10], which indicates that Veterans are higher users of primary care services in the first five years following release from the CAF. These rates are consistent with the self-reported findings from the Life After Service Study in 2013 that reported 81 % (79–83 %) of Veterans have a family doctor [4]. This is also consistent with reported American Veteran health services utilization rates [14]. Veterans in Ontario who accessed primary care visited a family doctor 10 or more times over each 5 year period, almost half the rate reported in the US with a reported average rate of 3.5–3.8 visits per Veteran per year [14]. The physician visit and hospitalization count data were right skewed, with higher mean values than medians. This indicates that a few individuals are likely heavier users of these health services than the majority of Veterans, similar to non-Veteran service utilization in Ontario [15, 16].

Within users of primary care, older Veterans had a higher average number of family physician visits than younger Veterans. These differences are expected given the relationship between aging and disease, differences in the need for chronic disease care between the populations, and a potentially longer history of an occupationally demanding career [4, 17]. Understanding how burden of chronic disease, and occupational injuries may explain these higher utilization rates is an important step in interpreting these data and mobilizing the information to inform policy. In addition, understanding how previous usual healthcare utilization patterns may differ for active CAF members, where individuals often interact routinely with the CAF health system will be critical to understanding current use. Follow up on usual healthcare utilization patterns for RCMP Veterans will also be critical.

Utilization of public health services including inpatient services and emergency departments also appear high within each Veteran age category compared to what is known about the general Ontario population. In Ontario, the age-sex standardized rate of acute inpatient admission was approximately 7 per 100 people in 2010–2011 [18]. In our study, on average 10 % of Veterans were hospitalized in any of the five-year time frames following release, with those over age 50 being hospitalized more frequently. In 2000, 20 % of Ontarians visited the emergency department at least once, and over 20 % were from individuals less than 20 years old [19]. In our study, more than 30 % of Veterans visited the emergency department in the first five years following release. These results are especially interesting considering that we have not included mental-health related visits in our utilization results. Identifying an appropriate comparator group from the civilian population will be instrumental in understanding how the patterns of health services utilization of Veterans compare to the general population.

Gender and age are both highly associated with use of healthcare services and only age was considered in our presentation of healthcare utilization. Although female Veterans may have experienced different healthcare issues or gaps in healthcare related to their military service [20–23], fewer studies focus on the health and healthcare utilization of female Veterans due to small sample sizes. Because, on average 15 % of the CAF serving members are female and 20 % of the RCMP are female [24], the large numbers in this cohort will allow us to study male and female Veterans separately in the future. Canadian research studies describing age and sex standardized annual health services utilization rates to contrast with the general population are needed to develop a better understanding of how Canadian Veterans living in Ontario use the public healthcare system.

This study provides the first description of the of the public health services utilization of a cohort of Canadian Veterans living in Ontario. The results fill a gap in our knowledge about how CAF and RCMP Veterans transition to the public healthcare system and provide a picture of how healthcare services are used following release. This study finds consistent use of non-mental health services by Veterans, particularly in the first five years following release from the CAF & RCMP and regardless of age. The implications of this work will inform the planning and delivery of support to Veterans in Ontario. Future research could include additional information on publicly funded home care, long term care and rehabilitation institutions and provide gender and age specific rates of healthcare utilization more comparable to those reported for the general Canadian population. Future health services research for Veterans should also target understanding the provincial costs of caring for Veterans in addition to the costs of federally mandated programs in an aging population. The development of predictive models to identify high cost or high health services users within the Veteran population could also be useful for future healthcare planning in the provincial and federal government.

CAF, Canadian Armed Forces; CIHI-DAD, Canadian Institute for Health Information Discharge Abstract Database; ED, emergency department; ICD, international classification of disease; ICES, Institute for Clinical Evaluative Sciences; IQR, interquartile range; LHIN, Local Health Integration Network; MOHLTC, Ministry of Health and Long-Term Care; NACRS, national ambulatory care reporting system; OHIP, Ontario Health Insurance Plan; RCMP, Royal Canadian Mounted Police; RPDB, registered persons database; SD, standard deviation; VAC, Veterans Affairs Canada