The research, published in the Journal of General Internal Medicine, analyzed an extraordinary dataset: 1.6 million Veterans who made at least one emergency department visit between October 2022 and September 2023, generating 3.2 million individual visits. Of those Veterans, 185,392 were women, accounting for 362,347 emergency visits. The investigators, led by Dr. Jessica Faiz of the VA Greater Los Angeles Healthcare System and UCLA, drew on VA administrative records, community care claims data, and enrollment files to reconstruct where every visit occurred and why. Their central finding is deceptively simple: about 60 percent of women Veterans’ emergency visits took place in VA emergency departments, while the remaining 40 percent occurred in community settings paid for through VA Community Care, the program expanded by the MISSION Act of 2018 that allows Veterans to receive care outside the VA system.

That 60-40 split matters because the two populations flowing through each door are strikingly different. Women Veterans who used VA emergency departments were, on average, younger than their male counterparts, with a mean age of 50.2 years compared with 62.9 years for men. They were also more likely to be Black, representing 33 percent of women emergency users compared with 20.9 percent of men, more likely to be Hispanic, more likely to live in urban areas, and more likely to carry a service-connected disability, at 65.5 percent versus 50.1 percent. Most striking of all, 42.1 percent of women Veterans presenting to emergency departments had a serious mental illness, nearly double the 23.4 percent prevalence among men. The picture that emerges is of a high-need population whose emergencies are intertwined with mental health, housing instability, and the long shadow of military service.

To untangle why some women end up in VA emergency departments and others in community ones, the team deployed logistic regression with generalized estimating equations, a statistical technique that accounts for the fact that the same patient may appear many times in the dataset across repeated visits. The models adjusted for age, race, ethnicity, rurality, comorbidity burden measured by the Elixhauser index across 31 chronic conditions, serious mental illness, housing instability, combat exposure, military service branch, VA enrollment priority group, driving time to the nearest VA emergency department or urgent care clinic, and the frequency of primary care contact in the preceding year. The result is one of the most comprehensive adjusted portraits of emergency care navigation ever assembled for this population.

The diagnosis a woman carries through the door turns out to be one of the strongest predictors of where she will be treated. Women with low-acuity conditions, things like upper respiratory infections, sinusitis, low back pain, and skin disorders, had 62 percent higher odds of being treated in a VA emergency department than in the community. Behavioral health-related visits also tilted toward VA settings, with 10 percent higher odds. The pattern likely reflects the financial predictability of VA care: for non-urgent problems, Veterans may reasonably prefer a system where copays are transparent and coverage is guaranteed, rather than risk surprise bills or gaps in Community Care authorization. In contrast, women presenting with emergency care-sensitive conditions, the time-critical diagnoses such as myocardial infarction and stroke where rapid, high-quality treatment demonstrably reduces death and disability, had 39 percent lower odds of receiving care at a VA facility. Chest pain was the single most common diagnosis among women treated in community emergency departments, while musculoskeletal pain topped the list at VA sites.

Geography exerts an equally powerful force. Women who lived farther from a VA emergency department were substantially more likely to seek care in the community, a finding that aligns precisely with the intent of the MISSION Act, which was designed to relieve Veterans facing geographic barriers to VA facilities. Distance also appears to shape the behavior of women experiencing homelessness, who had 10 percent lower odds of using VA emergency care. The authors suggest that fragmented care and lost continuity with VA services, chronic challenges for homeless-experienced Veterans, may push this group toward whatever emergency department is closest, regardless of affiliation. Notably, women with pregnancy-related diagnoses had the lowest odds of any group of presenting to a VA emergency department, consistent with the fact that most women Veterans receive obstetric care outside the VA system entirely.

Perhaps the most socially consequential finding concerns race and trust. Women Veterans from racially and ethnically minoritized groups had consistently higher odds of using VA emergency departments than White women, even after adjusting for clinical and geographic factors. The researchers offer two non-exclusive explanations: this may signal genuine trust in VA providers, a phenomenon documented in prior studies of women Veterans’ healthcare experiences, or it may reflect structural barriers, cost, insurance status, provider availability, that make community care harder to reach. Either way, the pattern echoes earlier national data showing that minoritized Veterans rely more heavily on VA-provided care across the board. It also raises the stakes for equity in emergency settings, where split-second clinical decisions intersect with providers who, as the broader literature on implicit bias in emergency medicine shows, are not immune to the cognitive shortcuts that can shape outcomes.

Combat exposure emerged as another unexpected predictor. Women Veterans with a history of military combat had 20 percent higher odds of seeking emergency care at VA facilities. The authors speculate that this may reflect the comprehensive post-combat care the VA offers, a stronger institutional connection among combat Veterans, or the higher rates of service-connected disability that qualify them for lower copays. Whatever the mechanism, the finding reinforces a theme running through the entire study: the VA emergency department functions not merely as a treatment site but as an anchor of institutional identity and trust for a subset of women whose needs span trauma, mental health, and physical medicine simultaneously.

The study’s technical rigor is matched by candid acknowledgment of its limits. Administrative data cannot capture clinical nuance, urgency, or patient preference, all of which influence where someone chooses, or is able, to seek care. The researchers could not distinguish ambulance arrivals from walk-ins, a crucial gap because community emergency department use for chest pain or stroke may reflect emergency medical services routing protocols rather than any deliberate choice. The analysis also captured only VA-paid visits, missing care covered by private insurance or Medicare. Missing race and ethnicity data, affecting 8.2 percent of women, were handled through multiple imputation by chained equations, and multicollinearity among predictors was formally assessed using variance inflation factors, all of which fell below 1.7 after collinear variables were removed.

The implications reach far beyond the VA. Because two in five women Veterans’ emergency visits now occur in community settings, and because those community visits are disproportionately the high-acuity, high-admission encounters most likely to require follow-up, the authors argue that care coordination between systems is no longer optional. They call for efficient exchange of emergency records, medication changes, and diagnostic results between community emergency departments and VA primary and specialty care; routine ascertainment of Veteran status at community registration desks; and automated notifications to VA care teams when a Veteran presents in the community. Within the VA itself, they point to the need for expanded behavioral health capacity, round-the-clock ultrasound and gynecologic consultation, and same-day services for lower-acuity concerns. As the population of women using VA healthcare has nearly doubled over the past decade, the study makes clear that the question is no longer whether women Veterans will receive emergency care in both systems, but whether both systems will be ready for them.

Subject of Research: Emergency department utilization patterns among women Veterans across VA and community care settings

Article Title: Where Women Veterans Seek Emergency Care: Patterns and Predictors of VA and Community Emergency Department Use

Article References: Faiz, J., Carvalho, C. J., Urech, T., Wu, S., Breland, J. Y., Frayne, S. M., Washington, D. L., Cordasco, K. M., & Vashi, A. A. (2026). Where Women Veterans Seek Emergency Care: Patterns and Predictors of VA and Community Emergency Department Use. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10847-z

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10847-z

Keywords: women Veterans, emergency department, Veterans Health Administration, VA Community Care, MISSION Act, behavioral health, health equity, care coordination, geographic access, homelessness, mental health, health services research

The clinical backdrop is sobering. Obstructive sleep apnea involves repeated collapse of the upper airway during sleep, producing intermittent oxygen desaturation, fragmented sleep, daytime sleepiness, and elevated long-term risks for cardiovascular and metabolic disease. The gold-standard treatment, continuous positive airway pressure, or CPAP, delivers pressurized air through a mask worn during sleep and is highly effective when used consistently. Yet registry-based cohort research, including a national Swedish study cited by the authors, has shown that a substantial fraction of patients fail to adhere to CPAP, and that treatment failure is associated with increased mortality. Educational, supportive, and behavioral interventions designed to boost CPAP usage have produced only modest and inconsistent benefits in Cochrane systematic reviews, suggesting that the field has not yet identified the levers that genuinely change patient behavior.

Carlson and her colleagues argue that one neglected lever is personal values. Their approach draws on acceptance and commitment therapy, a behavioral framework developed by Steven Hayes and colleagues and validated in a 2015 meta-analysis across a wide range of mental and physical health conditions. In this framework, values are not abstract moral positions but chosen life directions, such as being an engaged parent, maintaining physical health, or contributing to a community, that give meaning to daily actions. The idea is that health behaviors are more likely to be sustained when patients can connect them to what they personally care about. A CPAP mask is easier to tolerate, in this view, when wearing it is framed not as compliance with a prescription but as a step toward the energy and alertness needed to live according to one’s values.

To capture those values systematically, the research team turned to established psychometric instruments from the acceptance and commitment therapy literature, including the Bull’s-Eye Values Survey developed by Tobias Lundgren and colleagues and the Valued Living Questionnaire described by Kirkman Strobs Wilson and collaborators. These tools ask respondents to identify the domains of life that matter most to them, to rate how consistently their recent behavior aligns with those domains, and to indicate where they would like to direct more effort. Applying such instruments at the point of treatment initiation is methodologically significant: it captures patients’ priorities before the experience of therapy, success or failure, and clinical interaction can reshape their outlook, providing a baseline against which later adherence and quality-of-life outcomes can be interpreted.

The focus on women veterans is itself a deliberate scientific choice. Women are the fastest-growing segment of the veteran population, and the VA has invested substantially in women’s health research and care delivery, yet sleep disorders in women have historically been understudied relative to men. Sleep apnea in women can present differently, with symptoms such as insomnia, fatigue, and mood disturbance sometimes overshadowing the classic loud snoring and witnessed apneas that trigger referral in men. Women veterans also frequently navigate caregiving responsibilities, employment, and the physical and psychological sequelae of military service, all of which shape how a nightly medical device fits into a life. Understanding what this population values, the authors contend, is a prerequisite for designing sleep apnea care that they will actually want to use.

The new study builds directly on the group’s earlier work with chronic insomnia. In a 2024 paper in Behavioral Sleep Medicine, Kathryn Saldaña, Gwendolyn Carlson, and the same Los Angeles-based team examined the values expressed by women veterans receiving cognitive behavioral treatment for chronic insomnia disorder, the first-line therapy for that condition. That line of inquiry emerged from the VA’s broader transformation toward a Whole Health system of care, described by Bokhour and colleagues in Medical Care in 2020, which explicitly reorients clinical practice around what matters most to each patient rather than around diseases alone. Extending the values assessment from insomnia to sleep apnea is a logical next step, because the two disorders co-occur frequently and demand different kinds of daily commitment: insomnia treatment requires behavioral change during waking hours, while apnea treatment requires wearing equipment through the night.

The study was conducted within a registered clinical trial, NCT03377452, approved by the VA Greater Los Angeles Institutional Review Board, with written informed consent obtained from all participants. The research team spans an unusually broad set of disciplines, including health services research, geriatrics, pulmonary medicine, nursing, psychiatry, and psychology, reflecting the recognition that sleep apnea care is not delivered by a single specialty. Funding came from a VA Health Services Research and Development Merit Award, with additional support from the National Institutes of Health and the VA Office of Academic Affiliations. The authors note that participants did not consent to public sharing of their raw data, a constraint that shapes how the findings can be reanalyzed but does not diminish the value of the published summary.

Why should a values-based approach matter for the hardest problem in sleep apnea care, namely long-term adherence? Research on CPAP use has shown that social context plays a role: a dyadic perspective study by Lu and colleagues in Sleep Medicine Reviews highlighted how spousal involvement influences whether patients keep using their machines. Values assessment adds a complementary, intrapersonal dimension, giving clinicians a structured way to discuss why treatment is worth the inconvenience. It also aligns with parallel work by Fung, Martin, and colleagues, who developed and tested a patient decision aid for older adults with obstructive sleep apnea, published in the Journal of Clinical Sleep Medicine in 2021, designed to improve person-centered decision-making. Together, these efforts sketch a model in which the clinical encounter begins not with a prescription but with a conversation about the patient’s goals.

The implications extend beyond the VA. If values expressed at treatment initiation predict subsequent engagement with CPAP or other apnea therapies, a brief values inventory could become a low-cost screening tool embedded in sleep clinics everywhere, flagging patients whose priorities are in tension with the demands of therapy and who might benefit from tailored counseling. More broadly, the study contributes to a quiet revolution in behavioral medicine: the recognition that adherence is not simply a matter of education or motivation, but of meaning. For women veterans, a population that has served and often struggled in silence, being asked what they value, rather than merely what symptoms they have, may itself be a therapeutic act. As the VA and health systems worldwide push toward whole-person care, this research letter offers a concrete, testable method for making that aspiration measurable, one patient and one night of better sleep at a time.

Subject of Research: Personal values reported by women veterans at the start of obstructive sleep apnea treatment

Article Title: Values expressed by women veterans initiating treatment for sleep apnea

Article References: Carlson, G. C., Gomez, G., Carlson, K. J., MacCabe, C. H. G., Gold, A. I., Erickson, A. J., Saldaña, K., Kelly, M. R., Song, Y., Zeidler, M. R., Fung, C. H., Alessi, C. A., Washington, D. L., Yano, E. M., & Martin, J. L. (2026). Values expressed by women veterans initiating treatment for sleep apnea. Journal of Clinical Sleep Medicine, 22(1), Article 189. https://doi.org/10.1007/s44470-026-00179-4

Image Credits: AI Generated

DOI: 10.1007/s44470-026-00179-4

Keywords: sleep apnea, women veterans, CPAP adherence, patient-centered care, acceptance and commitment therapy, values assessment, VA health care, behavioral sleep medicine, whole health, treatment initiation, quality of life, sleep disorders

The research team, led by investigators including Ramin Ebrahimi, Paul A. Dennis, and Jennifer A. Sumner, drew on national electronic health records spanning 2000 to 2019, a period covering multiple military service eras. Women veterans represent the fastest-growing group within the Veterans Health Administration, nearly tripling in number from roughly 160,000 in 2000 to nearly 440,000 in 2015, and they are projected to account for nearly 18 percent of all living US veterans by 2040. Yet despite carrying a heavier burden of both psychiatric and traditional cardiovascular risk factors than civilian women or male veterans—and experiencing higher cardiovascular mortality—they have been strikingly underrepresented in research on the PTSD-heart disease connection.

Methodologically, the study was designed to guard against the confounding that has plagued earlier work in this field. The investigators identified 622,312 women veterans with at least one VHA healthcare encounter, then excluded anyone with pre-existing cardiovascular disease. From this pool, 140,210 women with documented PTSD were matched to 101,448 women without the disorder using propensity score methods. Rather than relying on conventional statistical matching, the team employed extreme gradient boosting, a machine learning algorithm that iteratively models residuals to capture complex interactions among dozens of variables, including demographics, traditional risk factors such as hypertension and smoking, female-specific risks like preeclampsia, and a range of mental health conditions from depression to substance use disorders.

The matching process achieved excellent balance across all measured covariates, with standardized mean differences falling below the conventional threshold of 0.10. The resulting cohort had a mean age of 39.1 years, with fewer than 5 percent aged 60 or older, and was notably diverse: just over half were non-Hispanic White, roughly 30 percent non-Hispanic Black, and more than 9 percent Hispanic/Latina. Cardiovascular outcomes were identified using strict diagnostic code criteria—requiring at least one inpatient or two outpatient records for each condition—an approach validated in prior Department of Veterans Affairs research with reported sensitivity and specificity above 0.95 for PTSD identification.

Over an average follow-up of roughly six years, 7.5 percent of women with PTSD developed at least one of the cardiovascular conditions in the composite outcome, compared with 5.5 percent of women without PTSD—a 36 percent relative increase in crude cumulative incidence. In survival models accounting for the competing risk of death, PTSD was associated with a 24 percent higher rate of incident cardiovascular disease overall. The association held for ischemic heart disease, with a hazard ratio of 1.30, and for stroke and transient ischemic attack, with a hazard ratio of 1.29, consistent with meta-analytic estimates from earlier studies that had reported pooled hazard ratios of approximately 1.6 for coronary heart disease and stroke.

What distinguishes this study is its reach beyond the familiar territory of heart attacks and strokes. The researchers found significant associations between PTSD and heart failure, venous thromboembolism, pulmonary hypertension, and aortic valve stenosis. The link with venous thromboembolism was among the strongest observed, with a hazard ratio of 1.34, while aortic stenosis showed a hazard ratio of 1.23 and pulmonary hypertension 1.17. Associations with atrial fibrillation and peripheral arterial disease were elevated but did not reach statistical significance, possibly because these conditions remain rare in a cohort of women in their late thirties followed for only about six years.

Perhaps the most striking findings emerged from stratified analyses. The PTSD-cardiovascular connection was strongest in the youngest women: those aged 30 to 39 showed a hazard ratio of 1.52, and those aged 18 to 29 a hazard ratio of 1.42, compared with more modest elevations in older age groups. Racial and ethnic disparities were equally pronounced. American Indian/Alaska Native women with PTSD had a 58 percent higher rate of cardiovascular disease, and Hispanic/Latina women a 50 percent higher rate, compared with their counterparts without PTSD. The authors caution that small sample sizes for some subgroups produced wide confidence intervals, but the pattern suggests that certain populations may bear a disproportionate share of PTSD-related cardiovascular risk.

The biological plausibility of these associations rests on well-characterized pathways. PTSD has been linked to unhealthy behaviors including physical inactivity, poor diet, disrupted sleep, and smoking, as well as to comorbid depression and substance use disorders that independently elevate cardiovascular risk. Beyond behavior, the disorder involves dysregulation of the hypothalamic-pituitary-adrenal axis and hyperreactivity of the sympathetic nervous system, particularly in response to trauma-related reminders. These stress-system disturbances can drive vasoconstriction, endothelial dysfunction, arterial stiffness, and increased cardiac afterload—mechanisms that plausibly contribute to ischemic heart disease and stroke. Immune dysregulation and chronic systemic inflammation, also documented in PTSD, may underlie connections to heart failure and pulmonary hypertension specifically.

Notably, prior work by the same research group found that traditional and nontraditional risk factors together explained less than half of the association between PTSD and incident ischemic heart disease in women veterans, implying that much of the excess risk operates through pathways not yet captured in electronic health records. The authors call for mechanism-focused research into modifiable factors such as sleep patterns, physical activity, and trauma-related processes, which could open new avenues for prevention tailored to this high-risk population.

The clinical implications are difficult to ignore. Current cardiology guidelines have historically categorized women under 45 as low-risk for cardiovascular events, and the most recent VA/Department of Defense dyslipidemia guidelines recommend screening only from age 40, with no mention of PTSD status. Yet this study found the strongest PTSD-related risk precisely in women under 40, and earlier research showed that ten-year cardiovascular risk rises steadily from age 30 in women veterans. The findings argue for earlier and more tailored cardiovascular risk assessment in women veterans with PTSD, and the Veterans Health Administration has begun developing a Cardiovascular Toolkit aimed at improving risk identification and patient education for women veterans. The researchers also emphasize the need to determine whether similar early risk elevation exists in non-veteran women and men with PTSD, to verify the novel associations with aortic stenosis and pulmonary hypertension, and to test whether targeted interventions can blunt the cardiovascular toll of trauma-related illness.

Subject of Research: The association between posttraumatic stress disorder and incident cardiovascular disease in women veterans

Article Title: Impact of posttraumatic stress disorder on incident cardiovascular outcomes in women veterans: a retrospective longitudinal study

Article References: Ebrahimi, R., Dennis, P. A., Alvarez, C. A., Shroyer, A. L., Beckham, J. C., & Sumner, J. A. (2026). Impact of posttraumatic stress disorder on incident cardiovascular outcomes in women veterans: a retrospective longitudinal study. eClinicalMedicine, 100, Article 104197. https://doi.org/10.1016/j.eclinm.2026.104197

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104197

Keywords: PTSD, cardiovascular disease, women veterans, heart failure, venous thromboembolism, aortic stenosis, pulmonary hypertension, stroke, ischemic heart disease, propensity score matching, Veterans Health Administration, health disparities