Healthcare access challenges and opportunities among patients with medical complexities, U.S. military Veterans and women with uterine fibroids

Abstract:While access to medical care is essential to preventing disease, maintaining health, and managing acute and chronic illness, healthcare access is a varied experience in the U.S., underscoring the need to examine access challenges across populations, and especially among those with complex medical needs. This dissertation examines the role of healthcare access in shaping population health outcomes among two distinct populations, U.S. military veterans and women with uterine fibroids. The first study examines financial barriers to medical care between veterans and non-veterans, and veterans with and without Veteran Health Administration (VA) coverage using bivariate logistic regression with inverse propensity weights. Veterans and veterans with VA coverage were less likely to report financial barriers to care relative to comparable control groups. Lower financial barriers to care among veterans may be partly explained by access to enabling resources such as VA benefits, including VA medical care. These positive findings may reflect the VA’s integrated approach to healthcare. The second study assesses bivariate relationships between fibroid diagnosis, and sociodemographic, clinical, and psychosocial characteristics. Women with fibroids were significantly more likely to be Black, older, have a history of hypertension and reproductive surgeries, and have more prevalent menopause and emotional symptoms compared to women without fibroids. In analyses stratified by menopause status, the number of meaningful differences in menopause symptom prevalence by fibroid diagnosis was greatest in premenopausal women, with heightened prevalence observed in women with fibroids. In comparing premenopausal and early perimenopausal Black and White women with fibroids, White women reported greater adversity for select psychosocial outcomes while Black women had greater clinical and socioeconomic disadvantages. These findings shed light on women’s experiences with fibroids and the menopause transition, underscoring the need for future research to examine how fibroids and menopause symptoms jointly affect women’s physical and emotional health. The third and final study examines the association between fibroid diagnosis, Health-Related Quality of Life (HRQOL), and mental health symptoms using linear mixed-effects models with an unstructured covariance matrix. Women with fibroids compared to those without fibroids had significantly greater HRQOL disability for vitality, bodily pain, and social functioning, and higher anxiety symptom burden. Fibroid symptom proxies for adverse menstrual characteristics moderated the relationship between fibroid diagnosis, and vitality and bodily pain scores, such that women with fibroids had significantly greater HRQOL disability. Integrating patient-centered perspectives into clinical care may not only improve health outcomes among women with fibroids, but it may also enhance the effectiveness of fibroid policy proposals. The determinants that facilitate or impede access to care are numerous and ultimately influence the health and well-being of populations. Careful consideration of these multifaceted and interrelated factors is essential for effectively evaluating and addressing the healthcare needs of medically complex patient populations.