# Presentation: 043321

## The Changing Face of  VA: Opportunities in Women’s Health Research 

- Patty Hayes, Ph.D.
- Chief Consultant,
- Women Veterans Health
- Strategic Health Care Group
- December 2008

## Roadmap

- Changing Demographics
- Underutilization of VA by Women
- Fragmented Primary Care
- Quality differences
- Redesigning Primary Care for Women Veterans
- Comprehensive Primary Care
- Post-Deployment Health Issues
- Outstanding Opportunities for Researchers

## Where are we and where is Women  Veterans Health going?

## Expanding Population

- The number of women veterans is growing rapidly.
- Because of the large number of women on active duty and entering military service, the percentage of female veterans is projected to increase.
- from 7.7 percent in 2008
- to 10.0 percent in 2018
- to 14.3 percent in 2033
- High utilization by women who served in Operation Iraqi Freedom & Enduring Freedom (OIF-OEF)
- Over **102,126**  Female OIF-OEF Veterans
- 44.2% of women enroll, 43.8% use from 2-10 visits

## Women Veteran Trends

## Women Active Duty Service Personnel by Branch of Service (Sept 07) 

| Branch of Service | Women as a % of Total Personnel | Number of Women | Officers | Enlisted |
| --- | --- | --- | --- | --- |
| Army | 13.7% | 71,100  | 12,983 | 58,117 |
| Navy | 14.7% | 48,755  | 7,611 | 41,144 |
| Marine Corps | 6.3% | 11,706  | 1,138 | 10,568 |
| Air Force | 19.6% | 64,430  | 11,835 | 52,595 |
| Coast Guard | 12.2% | 4,950  | 1,160 | 3,790 |
| Reserve & Guard | 17.6% | 145,769  | 22,131 | 123, 638 |

**Women Active Duty Service Personnel by Branch of Service (Sept 07) **

## Women Veterans Using VA 

**Notes:**
14% in Active Duty, Guard and Reserves today[1].The proportion of female veterans (relative to male veterans) has actually increased over the last decade or so because (a) of the increasing number and proportion of women entering (and leaving) the military, (b) a more favorable survival rate of women compared to men at any given age, and (c) the younger age distribution of women veterans compared to male veterans. [2]
This means that the numbers of women in veteran status has climbed to 1.7 million today- or 7% of all living veterans[3].
[1] Women Veterans: Past, Present, and Future, Revised and Updated, September, 2007, pg 7
[2] Ibid.
[3] VetPOP  2004 Data, Office of Policy and Planning, December, 2007

## Women Veterans Are Younger

- Average age of VA users
- Female veteran = 48
- Male veteran = 61
- Among women veterans returning from OEF/OIF:
- 85.5% are below age 40
- 58.9% are between ages 20-29

| OEF/OIF Female Veteran Utilization |  |  |  |
| --- | --- | --- | --- |
| Age Group | Frequency | Percent | Cum % |
| Under 20 years | 3655 | 8.1% | 8.1% |
| 20–29 | 26,182 | 58.0% | 66.1% |
| 30–39 | 8,668 | 19.2% | 85.3% |
| 40 and over | 5,996 | 13.3% | 98.6% |
| Unknown | 651 | 1.4% | 100% |

- VA Healthcare Utilization Among 94,010 Female OEF/OIF Veterans through 1st Qtr. FY 2008 Environmental Epidemiology Service

**Notes:**
OEF/OIF veterans are changing the health care dynamic of the VA female population. Approximately 86% of OEF/OIF women veterans are under 40—much younger than all women veterans. This means more women of child-bearing age and the challenge of paying attention to issues specific to this age group while still providing the highest quality care to older women veterans.

## Women Veterans:Health Care 

- Traditionally, Women Veterans have under-utilized VA Health care
- majority receive health care outside VA
- Utilization data indicate current models of care delivery present barriers to women veterans using VA

## Women Veterans Are Younger

- Average age of VA users
- Female veteran = 48
- Male veteran = 61
- Among women veterans returning from OEF/OIF:
- 85.5% are below age 40
- 58.9% are between ages 20-29

| OEF/OIF Female Veteran Utilization |  |  |  |
| --- | --- | --- | --- |
| Age Group | Frequency | Percent | Cum % |
| Under 20 years | 3655 | 8.1% | 8.1% |
| 20–29 | 26,182 | 58.0% | 66.1% |
| 30–39 | 8,668 | 19.2% | 85.3% |
| 40 and over | 5,996 | 13.3% | 98.6% |
| Unknown | 651 | 1.4% | 100% |

- VA Healthcare Utilization Among 94,010 Female OEF/OIF Veterans through 1st Qtr. FY 2008 Environmental Epidemiology Service

**Notes:**
OEF/OIF veterans are changing the health care dynamic of the VA female population. Approximately 86% of OEF/OIF women veterans are under 40—much younger than all women veterans. This means more women of child-bearing age and the challenge of paying attention to issues specific to this age group while still providing the highest quality care to older women veterans.

## Needs of women veterans

- Clinics to serve the needs of young, working women
- Access, flexibility of hours, use of technology
- Address sexual health, family planning
- Many have childcare responsibilities and eldercare demands
- Many are employed, difficult to get time off for appointments
- Adjustment and depression issues
- Age related health effects
- Cardiac risk, obesity and diabetes, lung cancer, colorectal cancer, breast and cervical cancer screening, osteoporosis screening

## Fragmented Primary Care

- Women’s general health care and gender-specific health care often handled separately
- 67% of VA sites provide primary care in “multi-visit, multi-provider model:” primary care at one visit and gender-specific primary care at another visit.
- Too few primary care physicians trained in women’s health
- Inconvenient access to gender-specific care
- Mental health care separate from primary care

**Notes:**
The dominant model of primary care delivery in VA is fragmented, meaning that woman veterans typically visit their primary care physician for general health care needs, then visit a second provider who handles gender-specific health needs. Currently, 67% of VA sites provide primary care to women in this “multi-provider, multi-visit model.” Why? 
One of the reasons is that there are too few primary care physicians trained in women’s health. 
In addition, not all facilities are equipped with the necessary equipment.  
Some utilization data suggest that current models of care delivery present barriers to women veterans using VA.  
Integration of mental health into primary care is also essential to quality women’s health care. 
The fact is, women do not avail themselves of VA health benefits to the same degree as men do.

## Gender Differences in Quality

- Quality is high compared to the private sector
- Quality challenges - Significant gender differences in clinical prevention measures and mental health screenings.
- Most are similar to the private sector
- Cardiac risk measures lower for women
- Some are opposite the private sector:
- Influenza Immunizations- lower for women than men in VA

## Data on Quality and Delivery of Care

| Quality 
Comparisons | Women
VA Data 07 | VA Men & 
Women | Private Health
Insurance | Medicaid
Medicare |
| --- | --- | --- | --- | --- |
| Cervical Pap 
Smears | 91% |  | 81% | 66%
Medicaid |
| Mammograms | 86% |  | 69% | 49%
Medicaid |
| Colorectal CA
Screening | 70% | 78% | 55% | 53%
Medicare |
| Cholesterol | 80% | 92% | 83% | 71%
Medicaid |
| Diabetes
BP <140/90 | 71% | 77% | 61% | 57%
Medicaid |

- Source: VA  Hospital Quality Report 2008:

## Where is Women’s Veteran Health going?

## Redesigning Primary Care Delivery for Women Veterans

- Increase focus on quality of care issues and comprehensive longitudinal care for women veterans
- Gender specific care **is** primary care**.**
**Defining Comprehensive Primary Care for Women Veterans**:
- Availability of complete primary care from one primary care provider at one site.
- The primary care provider should, in the context of a longitudinal relationship, fulfill all primary care needs, including acute and chronic illness, gender-specific, preventive, and mental health care.

## Comprehensive Primary Care for Women Veterans

- Enormous undertaking by the VA
- Frame shift in the way care is delivered
- Our goal is to be a model of care for the nation
- The research opportunities are tremendous

## Accurately represent  the women’s veteran population through data and analysis	(demographics, epidemiology, health 	status, quality of care, etc).

- Provide Ongoing data by gender –
- Performance measures analyzed by VISN
- Analyze performance data points—OQP gathering data on reasons for differences in performance
- Best practices and innovations—
- Review high outliers
- Clinical and performance improvement grants

## Women Veterans Health: Additional New Initiatives

- Implementation of risk reduction in prescribing medications
- Contraception when appropriate
- Informed consent for teratogenic drugs
- Sex is a vital sign- provider/patient discussion of  sexual health

**Notes:**
Comprehensive Women’s Health Program:  to assess the quality of care and identify gaps in current clinics for women veterans.  A workgroup charged by the Under Secretary for Health is examining the services provided at each VA medical center to develop specific plans to fill in any gaps in care and assure high quality of that care provided to women veterans. 

Women’s Health Education: A series of mini-residency, hands–on training is being conducted for VA providers. Three mini-residencies will be conducted this summer at Madison, Palo Alto, and Baltimore and five more mini-residencies will be added in FY 09.
Quality and Performance Data: VA-wide quality and performance data on clinical prevention parameters are being analyzed to identify root causes of gender disparity. 
Birth Defects Prevention: 86% of returning OEF/OIF women veterans are under age 40. An initiative to prevent birth defects was implemented. VA providers are not currently well-versed in prescribing medications to women who may become pregnant.  This program will address increasing safety of prescribed drug use in women veterans of child bearing age by assisting clinicians to become aware of increased risk of birth defects when prescribing medications to this population. 
VA Medical Centers have received $32.5 million in FY08 Supplemental Funds specifically to improve women veterans’ health diagnostic capabilities. These funds have been used to purchase the following women’s health equipment:  
New on-site mammography at 32 Medical Centers with significant women veteran populations
Replacement of older equipment with state-of-the-art digital breast X-ray machines
Stereotactic imaging technologies and specialized ultrasound and biopsy equipment for state-of-the-art follow-up for breast cancer screening. 
35 DEXA scanners used to evaluate osteoporosis in all patient populations, particularly women have been purchased 
Specialized equipment to enhance other aspects of comprehensive women’s health such as colposcopy and cone biopsy for positive cervical cancer screening have been purchased as well as training for staff in these procedures. 

## Post-Deployment health in women: 

- High utilization by women who served in Operation Iraqi Freedom & Enduring Freedom (OIF-OEF)
- Over **102,126**  Female OIF-OEF Veterans
- 44.2% of women enroll, 43.8% use from 2-10 visits
- We don’t understand the reasons for this high utilization among this group
- This group is a large and rapidly expanding cohort with unique needs

## Post-Deployment health in women:

- Menstruation issues
- Tracking use of contraceptives
- 	Consequences of continuous use
- Pregnancy and pregnancy outcomes, including miscarriages
- Infertility
- Urinary tract infections
- Anecdotal reports of high rates
- More chronic presentations
- Heat, poor hydration, less access to toileting and hygiene
- Possible Exposures
- Concerns about toxic substances, animal “exposures”
- Evaluation for Depleted uranium exposure from munitions and shielding
- Injury patterns

## Readjustment issues

- Transitioning to home and “mom”role
- Differences for active duty, guard, reserve
- Attachment disruption and parenting issues
- Social supports network near military bases vs Guard, Reserve community based
- Transitioning active duty “job” roles to private sector: a step-down for women?
- Readjustment vs PTSD Diagnosis

## Summary

- Shrinking total veterans population but a **doubling of women veterans** using VHA for their healthcare
- Increasing recognition of women veterans’ unique and complex health needs—gear up for influx of younger  women veterans
- Improve Quality performance for women-seek best strategies and implement change
- Increase attention to comprehensive view of women’s health—beyond reproductive health issues
- Redesign primary care service delivery for women
- Understand post-deployment health issues for women
- Tremendous research opportunities

## Thank you for your interest in Women’s Health Research

**Questions?**