title: Access to the US Department of Veterans Affairs health system: self-reported barriers to care among returnees of Operations Enduring Freedom and Iraqi Freedom.
abstract: BACKGROUND
  The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans.
  
  
  METHODS
  We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care.
  
  
  RESULTS
  Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care.
  
  
  CONCLUSIONS
  This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.
authors.affiliation: School of Nursing, College of Health and Human Services, The University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223, USA. Celnitsky1@gmail.com.
authors.forename: Christine A
authors.initials: CA
authors.lastname: Elnitsky
authors.forename: Elena M
authors.initials: EM
authors.lastname: Andresen
authors.forename: Michael E
authors.initials: ME
authors.lastname: Clark
authors.forename: Suzanne
authors.initials: S
authors.lastname: McGarity
authors.forename: Carmen G
authors.initials: CG
authors.lastname: Hall
authors.forename: Robert D
authors.initials: RD
authors.lastname: Kerns
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000368:Aged; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration* / Q000706:statistics & numerical data; D014728:Veterans / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000534:rehabilitation; D055815:Young Adult