# Presentation: 802205

## VA Women’s Health Care Delivery & Quality:Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholders

- National VA QUERI Meeting
- Phoenix, AZ  December 11, 2008

- Center for the Study of
- Healthcare Provider Behavior

## Workshop Leaders

- Patricia Hayes, PhD
- Chief Consultant, Women Veterans Health Strategic Healthcare Group
- Steve Wright, PhD
- Director of Epidemiology, VA Office of Quality & Performance (OQP)
- Donna Washington, MD, MPH
- Core Investigator and Staff Physician, VA Greater Los Angeles Healthcare System
- Becky Yano, PhD, MSPH
- Research Career Scientist, VA Greater Los Angeles HSR&D Center of Excellence

## Workshop Objectives

- Educate QUERI researchers and system partners about what is known about:
- how women veterans use the VA,
- their physical and mental health burdens, and
- how VA care is organized to meet their needs
- Highlight the WVHSHG’s strategic plans and needs around women veterans’ QI
- Report on gender disparities in VA performance measures
- Discuss approaches to ensuring representation of women veterans in QUERI programs

## Slide 4

## Effectively Integrating Women Veterans into the Mindset of QUERI Stakeholders:How Do We Get From Here to There?Becky Yano, PhD, MSPH

- National VA QUERI Meeting
- Phoenix, AZ  December 11, 2008

- Center for the Study of
- Healthcare Provider Behavior

## Perceived Barriers to Integrating Women into QUERI Efforts

- Too few to effectively integrate
- Small sample sizes  not enough cases to analyze subgroups  end up wasting data
- Difficult to recruit  different utilization patterns (where are they?)
- Primary care based recruitment may miss them
- Women’s clinics highly variable  some comprehensive and some paps only

## Perceived Barriers to Integrating Women into QUERI Efforts

- Greater dual use among women vets?
- Different insurance status  more likely to use VA and non-VA than male vets
- Higher use of fee basis and contract care  incomplete portrait of their care
- Are they so different that your intervention doesn’t map to their needs?

## Women Veterans

- HIV/Hep C

- Diabetes

- Ischemic
- HD

- Mental
- Health

- Stroke

- Congestive
- HF

- Spinal Cord
- Injury

- Polytrauma

- Substance
- Use Disorders

-  What is the prevalence by gender
-   outside the VA?
-  Does age, health, dxs influence
-   likelihood WVs are part of registry?
-  Would your interventions vary if
-   women were explicitly included?

## Adapting QUERI Studies/Trials for Women Veterans

- Mental Health QUERI
- Women’s mental health clinics (RRP)
- Women’s Health TIDES?
- HIV/Hepatitis QUERI
- HIV screening in women’s clinics?
- Spinal Cord Injury QUERI

## Adapting QUERI Studies/Trials for Women Veterans

- Congestive Heart Failure QUERI
- Diabetes QUERI
- Ischemic Heart Disease QUERI

## Adapting QUERI Studies/Trials for Women Veterans

- Stroke QUERI
- Substance Use Disorders QUERI
- Polytrauma QUERI

## Gender Disparities

- Any evidence of gender disparities in each QUERI?
- VA EPRP measures suggest work needed in
- Diabetes QUERI
- Mental Health QUERI
- Others?
- Other evidence of gender differences in access to, use, costs, quality of care?

## Hypotheses about Differences

- Why do you think we are seeing these differences in VA quality of care for women?

## Going Beyond QUERI Centers

- How to accelerate building evidence base and implementing QI interventions?
- Top WH conditions differ from those of men
- Can QUERI Centers and/or individual researchers take these issues on?
*Ex*: Partner Mental Health QUERI x National Centers for PTSD  QI for PTSD/MST for WVs
*Ex*: Less breast conserving surgery in VA vs. private sector  how apply QUERI methods to investigate, identify determinants and remedy?

## Technical Support

- What kind of information/support do you need in order to integrate women veterans into your portfolio?
- Organizational variations in care?
- Patterns of utilization?
- Local women’s health program manager contacts?
- Clinical, health status, demographic data?

## Sources of Collaboration to Leverage QUERI Efforts

- Women Veterans Health Strategic Healthcare Group as partner
- Women Veteran Program Managers (dedicated FTEE/VA facility with WH expertise)
- Women’s Health Fellowship Program sites
- Women’s Health Clinical Centers of Excellence (e.g., Palo Alto)
- Consortium of VA-based women’s health researchers

## Active VA Women’s Health Researchers

- 4 DCMs

- 2 DCMs

- 8 DCMs

- 2 DCMs

- WASHINGTON
- BEAN-MAYBERRY
- YANO
- VA Greater LA

- FRAYNE
- TIMKO
- VA Palo Alto

- KIMERLING
- National Center
- for PTSD

- BASTIAN
- CHIREAU
- VA Durham

- SHIPHERD
- RESICK
- VOGT
- SEAVER
- VA Boston

- SCHNURR
- VA White
- River Junction

- VERNON
- Univ Texas

- WEISMAN
- Penn State

- LUTHER
- VA Gainesville

- SADLER
- VA Iowa City

- MURDOCH
- POLUSNY
- ENSRUD
- VA Minneapolis

- MAGRUDER
- VA Charleston

- BRADLEY
- HAMMOND
- KLUTE
- VA Puget Sound

- BRADLEY
- VA Roseburg

- YEE
- VA Albuquerque

- KRESSIN
- VA Bedford

- SAMBAMOORTHI
- TSENG, POGACH
- VA East Orange

- SURIS
- Dallas VA

- McNEIL
- BORRERA
- VA Pittsburgh

- WEAVER
- LA VELA
- Hines VA

- BOOTH
- VA Little Rock

- KREIN
- VA Ann Arbor

- HASKELL
- BRANDT
- JUSTICE
- MADDOX
- VA West Haven

## Questions ?

## More VA Women’s Health Care Research Has Been Funded

- Impact of practice structure on quality of care for women veterans (Yano)
- Gender equity in VA quality (Bean-Mayberry)
- Chronic physical and mental illness care in women veterans (Sambamoorthi)
- Quality of breast cancer care in VA (Luther)
- Fragmentation of care and unmet health care needs (Washington)
- Determinants of changes in how VA women’s health care is organized (Yano)

## More VA Women’s Health Care Research on OIF/OEF Funded

- Sexual violence and gynecologic health (Sadler)
- Evaluation of MST screening/treatment (Kimerling)
- MST effects on PTSD and behavior among Marines (Shipherd)
- Physical and sexual assault in deployed women: risks, outcomes, services (Sadler)
- Stigma, gender and other barriers to VA care (Vogt)

## Brief Research Highlights

- New systematic literature review funded
- Focus on women veterans’ research has created a virtual “explosion” of new studies and new published results
- VA HSR&D funded an update of the review done in 2004 (published in _Journal of General Internal Medicine_ in 2006)
- Bevanne Bean-Mayberry, MD (PI) (GLA)

## New Women Veterans Cohort Study

- Women’s Healthcare Evaluation of Resource Utilization and Outcomes Assessment (HERA)
- OIF/OEF women veterans with matched men
- West Haven, CT and Indianapolis, IN initial cohorts
- Obtained additional resources to add other sites (e.g., Los Angeles, Tampa)
- Assess health care utilization, costs and satisfaction 2 years after discharge and after 2-year coverage ends
- Compare diagnosis/treatment of stress associated conditions during 2-year coverage period

*Source*:  Brandt, Haskell, Justice et al (2008-2011)
-               VA West Haven

## National Survey of Women Veterans

- New national survey funded by WVHSHG
- Objectives of new national survey are to:
- Identify current demographics, health care needs, and VA experiences of women veterans
- Determine how health care needs and barriers to VA health care use differ among women veterans of different periods of military services (e.g., OEF/OIF vs. earlier periods)
- Assess women veterans’ preferences for and perceived value of different types of VA interventions to improve access and quality
- From 2,500 to 3,200 will be surveyed across US
- Equal numbers of VA users and non-users

*Source*:  Washington (2007-09) (GLA)

## National Survey of Veterans

- Public law dictates decennial survey of veterans nationwide
- Contract for 2010 survey funded to Westat
- Funded to oversample women veterans
- Focus on outreach/education and issues of employability/transitions

## Evolution of VA Women’s Health Clinics

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

**Comprehensive Women’s**
**Health Centers Funded**

- Gulf War

- OEF*

- OIF*

**GAO**
**Report**

*Source*:  Yano EM, et al. Diffusion of VA women’s health clinics. *Women’s Health Issues*. 2006.

**GAO Report**

**GAO Report**

**WHC mandate**
**to “preferred”**

**Legislated WH service expansion**