# Presentation: 552939

## Women Veterans’ Health Care Needs and Use

- Donna L. Washington, MD, MPH
- Core Investigator and Staff Physician
- VA Greater Los Angeles Healthcare System
- December 2008

## Overview of Women Veterans’ :

- Physical and mental health burdens
- Organization of VA care to meet their needs
- VA health care use

## Women veterans’ have substantial chronic disease burden...

- Top diagnoses:
- Post-traumatic stress disorder (PTSD)
- Hypertension
- Depression
- Hyperlipidemia
- Chronic low back pain
- Gynecologic problems

*Source*:  Frayne et al.  VA Women’s Health Program Evaluation, 1999;  VA National Patient Care Database, 2004.

## ...and Substantial Physical / Mental Health Comorbidities

- Mental illness very high among women veterans with chronic conditions
- 31% of women veterans with diabetes screen positive for depression, anxiety disorder or PTSD
- 37% of women veterans with cardiovascular disorders (heart disease, CHF, stroke) have diagnosed depression

*Source*: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

## % of Veterans (VA users & nonusers) receiving treatment in prior year for selected QUERI conditions

| Condition | Female | Male | p-value |
| --- | --- | --- | --- |
| “Heart condition” | 9.6% | 16.4% | <.0001 |
| Stroke | 1.5% | 3.1% | .01 |
| Diabetes mellitus | 6.4% | 11.5% | <.0001 |
| HIV / Hepatitis C | 1.7% | 1.8% | NS |
| Substance use disorder | 0.8% | 1.3% | NS |
| Mental Health | 15.9% | 7.8% | <.0001 |

*Source*:  National Survey of Veterans 2001

## % of Veteran VA users receiving treatment in prior year for selected QUERI conditions, by gender

| Condition | Female | Male | p-value |
| --- | --- | --- | --- |
| “Heart condition” | 17.7% | 28.9% | .0023 |
| Stroke | 2.6% | 6.2% | .016 |
| Diabetes mellitus | 8.3% | 19.8% | <.0001 |
| HIV / Hepatitis C | 5.2% | 4.8% | NS |
| Substance use disorder | 2.0% | 2.9% | NS |
| Mental Health | 32.9% | 19.5% | <.0001 |

*Source*:  National Survey of Veterans 2001

## PTSD Prevalence and TreatmentWomen Veterans

|  | PTSD
screening test positive* | Mental health care use prior 12 months for PTSD +’s* |
| --- | --- | --- |
| All women veterans | 10.9% | 27.3% |
|    VA users | 26.0% |  63.7% |
|    VA-nonusers |   9.7% | 19.9% |

- *p<0.0001 for VA-user versus VA-nonuser comparison

*Source*: Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

## VA Health Care for Women Veterans

- Women veterans who use the VA have unique health care needs
- Lower functional status vs. male vets, non-vet women
- Special mental health care needs (PTSD, MST)
- Congressional eligibility reforms changed array of services available to women veterans
- Including mandated provision of gender-specific services
- VHA faces considerable challenges in meeting those needs
- Complicated casemix, growing caseload & services

## Expansion of VA Women’s Health Clinics & Women Veteran Caseload in VA Facilities (1985+)

- WV Health Program Act
- (P.L. 102-585)

- Comprehensive
- Women’s Health
- Centers Funded

- Gulf War

- OEF

- OIF

- GAO
- Report

*Source*:  Yano, Washington et al. Women’s Health Issues. 2006.

- Legislated WH service expansion

## What Does VA Women’s Primary Care Look Like Now?

*Source*: Yano, Washington,
- Bean-Mayberry, HSR&D #IIR 04-036 (2007)

- BUT 44% deliver
- gender-specific
- exams only

- GYN clinic 9%
- no GYN clinic 11%

## So What is the Problem?

- Primary care is fragmented for women veterans
- What would be routine primary care in community settings is referred out to specialty women’s health in VA
- 54% refer Pap smears
- 47% refer clinical breast exams
- 47% refer contraceptive counseling
- 46% refer vaginitis evaluation
- 46% refer menopausal management
- 16% refer osteoporosis management
- 15% refer sexual trauma screening

*Source*:  Yano, Washington, Bean-Mayberry (HSR&D #IIR 04-036) (2007)

## Integrated Primary Care

- 42% of VAs have designated WH providers in general PC to whom women veterans are preferentially assigned
- 56% have _one_ for whole PC practice
-   9% have _one_ in each PC team
- 18% have a WH primary care team
- Others:  randomly assigned, count NPs, no specifics
- Lack adequate clinical expertise in WH (p<.05)
- Lack same-gender providers (p<.01)
- Designated WH providers only available _6 half-day sessions/week_

*Source*:  Yano, Washington, Bean-Mayberry (VA HSR&D #IIR 04-036) (2007)

## Barriers to delivering high quality health care to Women Veterans

*Source:* Yano, Washington & Bean-Mayberry,
- VHA Survey of Women’s Health Programs & Practices, 2007.

- Space limitations or ability to assure privacy
- Small women veteran caseload
- Inability to recruit specialists
- Insufficient # clinicians skilled  in women’s health
- Competing local or network priorities
- Highly competitive health care market for women

## Women Veterans Use VA Differently

- Women veterans underutilize VA health care compared to male veterans
- Among VA users, women more likely to concurrently use VA   and non-VA healthcare

*Source:* FY2006 VA NPCD and 2000 US Census

## Women Veterans Use VA Differently

- Women have 11.8% more outpatient visits, 25.9% fewer inpatient days and 11.4% lower costs compared to men
- After adjusting for age and medical comorbidity, differences less pronounced (1.3%, 10.9%, and 2.8%)
- Among 30.8% of women and 24.4% of men with medical *and* mental health conditions, women use care more heavily (31.0 vs. 27.3 visits)
- Women 3x more likely to use fee basis care

*Source*:  Frayne et al, J Women’s Health, 2007 Oct; 16:1188-99.

## Lack of information about VA and perceptions of poor VA quality are barriers to VA use for Women Veterans

- Washington DL, et.al. *J Gen Intern Med*. 2006 Mar; 21:S11-18.

- VA quality of care rated high

- Perception that VA physicians not skilled in treating women

- Misperceptions of availability of VA women’s health services

- Knowledge gap for VA benefits

## Women veterans prefer . . .

- One-stop shopping
- Receiving general & women’s health care from the same provider or clinic rated  very important for 55% of VA users
- Availability of Women’s health clinics
- Rated very important for 44% of VA-users, 29% of VA-nonusers

- Washington DL, et.al. *J Gen Intern Med*. 2006 Mar; 21:S11-18.

## . . . but they often receive       fragmented care

- Different components of health care for women provided by different providers with varying degrees of coordination
- Women veteran VA users:
- 28% have one VA provider or clinic for both primary care and women’s health
- 21% receive primary care and women’s health from different VA clinics
- 51% concurrently use VA and non-VA for different components of care

*Source*:  Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

## Main Healthcare Service Used 

|  | VA 
users | VA nonusers |
| --- | --- | --- |
| Women’s health care | 27% | 24% |
| Other primary care | 28% | 50%  |
| Mental health care | 13% |   3% |
| Other specialty care | 12% | 14% |
| Prescription benefits | 14% |   6%  |
| Other |    6% |   2%  |

*Source*:  Washington & Yano, VA HSR&D #IAE 06-083, VISN22, 2004.

## Conclusions

- Co-morbid physical and mental health conditions
- Women’s health is cross-cutting issue for QUERI stakeholders
- Fragmentation of women’s health care inherent in VA delivery arrangements and in women veterans’ dual use of VA/non-VA systems of care
- Implications for coordination across sites of care and women veteran-focused interventions