Spotlight on Women Cyberseminar Series- 14 -Veterans’ Administration

January 31, 2012

# Veterans’ Administration

**Spotlight on Women Cyberseminar Series**

**January 19, 2012**

Molly:  At this time I would like to introduce our two presenters.  We have Dr. Rachel Kimmerling joining us.  She is a clinical psychologist at the Dissemination and Training Division of the National Center for PTSD at the VA Palo Alto Health Care System.  She is also an investigator at the VA HSR&D Center of Excellence, Center for Health Care Evaluation.  Her research interests are issues of women and gender and the detection and treatment of traumatic stress.  She is also Director for Monitoring at VA Office of Mental Health Services, Military Sexual Trauma Support Team.  Dr. Kimmerling and her team conduct Congressionally-mandated monitoring of military sexual trauma screening and treatment in VHA and respond to the Office of Mental Health Services needs for data concerning MST.

Joining her is Dr. Jenny Hyun and she is the Manager for Monitoring Data and Analytics for the Office of Mental Health Services, MST Support Team and was a post doctoral fellow in health services research at the Center for Health Care Evaluation at the VA's Palo Alto Health Care System.  She conducts health services research, with specific interests in the organizational factors that impact screening and treatment.  We are very lucky to have both of them presenting for us today and if you're ready at this time I'd like to turn it over to you ladies.

Jenny Hyun:  Dr. Kimmerling and I want to say how very excited we are to be presenting on VA administrative data and to be sharing the wealth of our knowledge and experience over the years, conducting both operational evaluation and research in MST.  Before we begin, [pause] we'd like to get a sense of who our cyber seminar audience is, so there are two poll questions related to your position at the VA and how familiar you are with VA administrative data on MST.  So that's the first question.   I'm going to give that over to Molly to put as the poll question.

Molly:  Thank you.  Yes, we do have the poll question on the screen at this time, so for our attendees, please just go ahead and check the circle next to the answer that best describes your role.  I will leave it open until we've heard from most of our attendees and we're at about two-thirds response rate right now, so we can leave it open for a few more seconds.    Okay.  The responses have started to slow down, so I'm going to go ahead and close the poll and share the results with everyone.  Jenny, do you see those on your screen?

Jenny Hyun:  I don't.

Molly:  The results?  Okay.  I'll walk through them real quick.  We do have thirty percent researchers joining us, eighteen percent clinicians, four percent MST coordinators, nine percent administrators or policymakers and thirty-three percent other.

Jenny Hyun:  Okay.  That's great.  It seems like we're getting a wide swath across the VA and the next question asks about familiarity with the VA administrative data on MST, so we know how much detail to go into when we start talking about MST data.

Molly:  Thank you, we already do have some responses coming in, so we'll give everybody a little bit of time to respond.    Okay.  We've had about eight-three percent people respond.  So thank you for those respondents.  I'm going to go ahead and close the poll out now and I'll share the results with everybody.  Jenny, can you see those results?  

Jenny Hyun:  I cannot.  

Molly:  Okay.  Give me one second here.  

Jenny Hyun:  Okay.  Here we go.  That looks like four percent are very familiar, fourteen percent moderately familiar, twenty percent somewhat familiar.  The vast majority, thirty percent, a little bit familiar and thirty-two percent not familiar at all.  So that's great, this is the right talk for you.  I think that there's a little bit of everything for everyone on this list, for people who are very familiar, this may be review, but also important--some data issues to keep in mind.  Then for some of you who are not so familiar, this will be an excellent introduction to VA administrative data on MST and will hopefully set you up for success in conducting research on using MST data.

As you can see from the topics list, I really wanted to start very broadly and give you some information about how we came to acquire so much knowledge about MST data.  So I wanted to give you some background on the Military Sexual Trauma Support Team and the very involved evaluation work that we do for the MST Support Team.  I also wanted to give you a very brief overview of MST screening and treatment, so how does MST data become MST data?  So how is it collected in the field and also to give you a brief context of the national data on MST screening and treatment.  

We'll delve into some of the MST data issues that we've encountered over the years and give you more information about how to access MST data in the administrative data sets.  We will touch very briefly on some of the research that we've done recently, using the VA administrative data on MST and then conclude with some ideas on future directions, which I'm sure others have a number of very bright ideas about future directions for research.

So to begin, the MST Support Team was established in 2006, so we've been doing this for quite a number of years and it was established by the Office of Mental Health Services to conduct legally mandated monitoring of MST screening and treatment.  We also oversee education and training related to MST.  We promote best practices for MST screening and treatment and offer policy recommendations related to MST for the Office of Mental Health Services.

We have two divisions, the Monitoring Division sits here at Palo Alto Health Care System, the Education and Training Division sits in Boston and together we're very complementary.  We make up the MST Support Team.

In terms of our evaluation activities, we've been prolific over the years.  We started with one report and now we are up to five.  Again these are all the annual reports that we do on MST screening.  We do one on MST-related outpatient care and then we do screening and outpatient care in CBOCs, specifically, the Community Based Outpatient Clinics and then we do a special report on our recently returned Veterans on the OEF/OIF/OND Veterans.  

In addition to these, we also do specially commissioned reports on investigating satisfaction with VHA care, which Dr. Kimmerling will talk about later in this presentation.  We've also done analyses on gender concordants, which is especially important for the population of Veterans who have experienced MST and we've also done some analyses, looking at MST-related mental health staffing.

Our annual reports are available to all VA employees.  The Intranet Web site address is on the top of the page, it's vawww.mst.va.gov, very easy to remember, and the arrow shows you where to go to find our annual reports and you'll find a lot of data, so we report both at the national level and at the facility level for all of the MST screening and treatment data that I just discussed.

The MST Resources Homepage also has a lot of other information for researchers who are just starting out, who want to learn more about how MST program is implemented in the field.  What kinds of regulations there are related to MST screening and treatment.  There are some training handouts that give a very brief overview of the things that all VA staff should know as well as other types of very brief introductory types of handouts.  You can find almost everything that you could possibly need on that share point site.  

The other thing I wanted to mention, for people who are interested in learning more about MST, we do offer a monthly teleconference training series call--if you're interested in receiving notification through those go to the share point site, the front page has information on who to contact to sign up for those calls.

Many of you know that MST encompasses both experience of sexual harassment and sexual assault.  What many of you may not know is that the definition of MST comes directly from public law.  So it is a term that is in U.S. code and it is also a term code and it is also a term that is specific to the VA.  So that's important to keep in mind when you are looking at research literature on MST, that it encompasses both of these terms and that it is a term that's specific to the VA.  You won't find that term used when looking at literature on active duty personnel.

So how is MST data at the VA actually collected?  Universal screening for MST began in Fiscal Year 2002, meaning that all Veterans who use the VHA facility are required to be screened for MST.  All Veterans are screened for MST once, using the MST Clinical Reminder in CPRS.  This is because MST is an historical event, so it either happened or it didn't and that's why we only screen once for MST.  

Although the screen is only given once, if someone discloses MST after the screening has occurred, if they disclose it to their provider, the MST screening status can always be changed and, again, directions on how to do that, if you're a clinician and that occurs to you, are also on the share point site.

Our latest directive is VHA Directive 2010-033, which you can also reference on the share point site.  It states that screening must be conducted in appropriate clinical settings by providers.  

These are the two questions that encompass the MST Screening Clinical Reminder one has to do with--captures experiences of sexual harassment, one captures experiences of sexual assault.  Veterans who respond positively to either item are considered to have a positive screen for MST.  This makes sense clinically because the VA is a medical center and health care is our primary objective--that any types of mental health conditions that arise from these experiences are treated exactly the same.  So no matter if you have depression that resulted from severe sexual harassment or coercion that is treated the same, regardless of whether it was limited to sexual harassment or sexual assault.  

The MST Screening responses--and all of these are valid responses to the treating item, "No", "Yes" or "Declined to Answer" and people should know that if a person does decline to answer, the Clinical Reminder resets and that person is due to be screened again in a year.

In terms of evaluating MST screening performance across facilities, we've learned a lot over the years.  After our first report was conducted, we wanted to make sure that we were consistent with the procedures that were already in place for monitoring performance measure.  So we've used the Office of Quality and Performance guidelines in terms of evaluating people who are screened for MST.  So the patient must be a Veteran, they must have had at least one outpatient encounter at a nexus clinic, but we have added one clinic a Women's Stress Disorder Treatment to the nexus clinic list that OQP uses.  So our methods are very consistent with OQP in terms of evaluating facility performance.

You'll see over the years the VA has increased dramatically in terms of the people who are screened for MST.  This slide shows you that currently at 2010 we are at 97.3 percent for both men and women in terms of screening for MST.  Again, this shows you that rates of people who screen positive for MST over the years.  We have found that the rates have been very consistent since we began monitoring MST since 2005.  Generally, for all Veteran VHA users in a given Fiscal Year about one in four women will screen positive for MST and one in one hundred men.  Those rates are slightly lower for special--OES/OIF/OND recently returned Veterans and we also did some analyses on the proportion of MST in homeless Veterans and you'll see those rates there.

As I mentioned, we do evaluate all facilities on MST screening and treatment. So across the VA that equates at 140 different facilities.  So the data issues that I'm going to talk about now impact only a handful of those facilities, but I wanted to mention them in case--researchers can keep that in mind when dealing with VA administrative data.  I had a colleague who recently began working and we talked about VA administrative data and she said, "Well, when I first started at the VA, I thought that all of the administrative data would be very clean."  As anyone who's worked with VA administrative data knows that there are always some issues that arise, so we wanted to share some of the issues that we've encountered, that we've discovered over the years.

One of the data issues that we discovered, that have come to our attention from time over the years is that there are some facilities that have different MST screening questions and, again, this really impacts only a handful of facilities.  Facilities are required to use the national version of the MST Clinical Reminder and that is spelled out in our latest VHA directive.  The MST Support Team has made a recent effort to standardize all of the Clinical Reminder language for the MST screen, so we have identified a small number of facilities that were using non standard questions and if that is important to you, in doing your research, please don't hesitate to give me a call and we can discuss that.  We have corrected all of the non standard MST Clinical Reminder questions as of Fiscal Year 2012.  

There were also one or two facilities that had implementation problems with their MST Clinical Reminders, so when they implemented their Clinical Reminders, the responses for a certain time or for a specific population of Veterans would default to a certain response and so those response options are not valid for those years.  

For example, at one facility, the MST Clinical Reminder was defaulting to "yes" for all Veterans who were newly screened during a specific period of time.  For more information about these facilities that you may not want to include, if you're doing a national study, you can refer to our annual MST reports, these facilities have been *grayed out* because of known implementation problems.  

Another issue that came to our attention for one of the facilities is that when facilities were modifying the Clinical Reminder, there were some issues that affected the transmission of data from the local facility to the national data warehouses and we identified one of the facilities that we worked with and that facility was also *grayed out* out of our report.  So on occasion that's also happened and again if you're conducting a study using national VA data, you should probably take the facility out for Fiscal Year 2010 when we identified the problem.

Molly:  Jenny, we have a clarification question.  Are those few facilities still using the non standard screening tool?

Jenny Hyun:  As of Fiscal Year 2012 all facilities should be using the standard Clinical Reminder questions.  Those facilities using non standard questions have been corrected.

Molly:  Great.  Thank you.

Jenny Hyun:  The last data issue that I wanted to mention is: There were some facilities that had either Clinical Reminder implementation problems or some errors when they were changing their Reminders that the Clinical Reminder was inadvertently turned off for say primary care or for a specific population of Veterans in their facility and those facilities, you can tell that they have low MST screening rates and that there's something amiss with their facility screening by looking at our reports and seeing what their screening rate is like.  If you want to do a study using the MST data nationally, you want to insure that facilities are screening at a very high rate and those facilities that are not, you may want to remove from your analyses.

So I'm going to turn the presentation over to Dr. Rachel Kimmerling, she'll give you more of an overview on MST-related treatment and some of the other research that we've done on MST.

Dr. Rachel Kimmerling:  Hi.  Before I move on to treatment, I just want to let you all know what a large amount of very amount of very comprehensive work Jenny has done to really standardize Clinical Reminder implementation.  I think it's relevant to research on MST,  but not only that, I think with the growing availability of VA administrative data--it's a great example for anyone who aspires to or is mandated to--for example, go into the CDW and pull down some health factors and try and characterize screening for other conditions.  There's just a lot of variability and how Clinical Reminders are implemented and mapped and aggregated and it's taken quite a bit of research and collaboration with other systems, such as OI&T, especially clinical applications, coordinators and as a whole, we found the system to be very responsive and the data is in much better shape than it used to be thanks to Jenny's efforts.

So now I'm going to move on some of the data regarding MST-related care.  There is a VA policy that all inpatient, outpatient and pharmaceutical care for physical and mental health conditions related to MST is provided free of charge.  Related to is completely in the judgment of a VA provider and there is an encounter checkbox that corresponds to DSS encounter designation by which a provider can code MST-related care.

We monitor the most frequent mental health diagnoses that are recorded as primary diagnoses on MST-related mental health conditions and those are PTSD, depression, schizophrenia and psychoses, substance abuse and mania and bipolar disorders.  So you can see that MST is associated with a wide range of mental health conditions that goes well beyond Post Traumatic Stress Disorder.

We don't monitor the medical conditions on MST-related encounters, but the research suggests that we're likely to see a lot of behaviorally linked conditions, such as liver disease, pulmonary disease, obesity, hypertension, as well as sexually transmitted infections and sexual dysfunction.

When we're looking at MST-related care, I think it's important to kind of qualify that we're not expecting to see a one-to-one correspondence between a positive screen and an MST-related encounter and that's because MST itself is an experience.  Really quite a few people who have this experience are resilient to it and may not go on to experience any related health and mental health conditions.  It is policy that VA clinicians offer services to all Veterans with positive screens, but as a result not all Veterans who record MST will require or desire care in any given year.  

We're still working on the standards by which we're evaluating sufficient level of care and resources devoted to MST-related treatment, but what we're happy to see is that overall the proportions of Veterans with positive screens, who are receiving MST-related mental health care in a given year are rising over time and we think that there's just generally a greater awareness of these services, increasing resources to this area and better training and how to appropriately document these services.  

Nationally among Veterans about half of women and thirty-seven, thirty-eight percent of men receive MST-related mental health encounter and these are among all Veterans with historical [inaudible] or historical MST screens because some people do go on to receive either care for quite a long period of time or it may be delay care and among, as you would guess, the newly returned Veterans where the experience is more recent, we see higher proportions and in the special report we did on homeless Veterans we see substantially high portions which was really nice to see that this population is having quite good access to MST-related mental health care.

So how do we look at these encounters?  There's quite a few encounters and the majority of these encounters are related to mental health care.  The uniform mental health services package  and some prior policy documents pointed to Clinic Stop 524 as the primary way to monitor MST-related care and please don't use that as an indicator.  Stop Codes are really clinic specific, so many facilities that do have specific MST clinics will use Stop Code 524 that is a stop code that cannot capture the wide range of conditions and settings in which people receive MST-related care, especially the care that's not mental health care.  That's why we really point to the encounter checkbox as the best indicator of MST-related care.  

That can be found in DSS--you only want to look at MST-related care within the population of folks that have a historical or positive screen for MST, because that's the sub population for whom it's relevant.  In the DSS outpatient extract there's a variable called MST and the values of that variable are yes, no and declined.  We [culled] declined screens for our reports because we assume that to mean that some provider did sit down with the Veteran and ask the questions and that's the obligation that we're measuring.  

A slight note, if you do decide to look at these data and for validity purposes, which we would recommend, doing some comparison with the national data that we have on the Web site, you may find slight differences because we get some additional data that gives us just a [skosh] more completeness, but I would say for research purposes--we're resolving some of these issues more and more that the DSS variables is what you really want to use and the most readily available.  

In the SE file there's another variable, helpfully also named MST, which indicates whether that encounter relates to military sexual trauma.  It is parallel to the DSS outpatient encounter designator that's MST encounter, MST underscored _ENC, which gives you the same information.  

You want to look at this Fiscal Year by Fiscal Year because we have screening data from '02 and encounter data from '06, so you'll want to just say--okay, for example, all of the Veterans with a MST screen in FY 10, let's look at their treatment within this Fiscal Year and that's the way you can reconcile these.

  A few other sticky issues is that because people can change their responses to the screen at any time and folks who are declined are re-screened, you'll find a certain number of patients with multiple responses and you'll need to resolve that.  Probably the best thing to do is use the most recent values because that will represent an updated reminder status.  

I'm sorry, I'm just talking and talking and the other thing, a question we get asked a lot is whether we can separate assault from harassment in this variable and we cannot.  We actually--to just repeat some of what Jenny said, we don't think that that's important.  There's some research that bears out kind of repeated harassment and sexual assault, kind of a load on the same construct when you look at these issues and in terms of VA's response and how we construe these to be mental health issues, there's not an important need to separate these experiences.  As with many things, there's a little bit of interest in gender data if you're trying to look at males versus females, I think your usual way of resolving this is it will probably work here, we don't do a lot of work with facilities outside of the U.S. that have kind of maybe slightly different VA missions in terms of MST screening and treatment, so you might want to, for example, take Manila out of your analyses.

We can talk a little bit about some of the research that we've done recently.  I'm going to talk a little bit about the data we did, linking this with the SHEP satisfaction survey and then turn it back to Jenny, where she can discuss some of the organizational factors' work that she's done.  We did get a request from OMHS to look at patient satisfaction among Veterans with MST, as the result of some inquiries from stakeholders who wanted to kind of ensure the quality of care that we're providing to Veterans who have experienced MST.

At the time, the most recent data available was Fiscal Year 2007.  We linked that, as I stated, to the SHEP, which has ten kinds of domains of satisfaction and we looked at each of these and we compared patients who reported MST to patients who did not report MST.  For this we really were limited to looking at the associations of MST with overall satisfaction with care rather than satisfaction with MST-specific mental health care per se because of the way that the SHEP constructs their sample and the end that we had as a result, but it is a nice kind of general representative sample.   We were heartened to find that MST was actually not associated with overall satisfaction ratings with health care after just seeing four relevant patient characteristics identified in previous work.  This stands in contrast to some of the literature we see in civilian and other public sector settings, where it look at patients who have experienced sexual trauma--actually rates many aspects of their health care more poorly than do other patients.  On male Veterans, there is no association between MST status and sub domains of health care satisfaction at all.  

We did find a specific finding in the sub domains of female Veterans, where they rated overall coordination and education and information significantly lower than women without MST and we think that this reflects more broadly women with complex medical and mental health co-morbidities as we tend to see among women with MST and that these women maybe are likely to perhaps desire a little bit more information and education and face additional challenges with coordination, coordinating multiple specialty care and providers and--here's our--just briefly to look at the overall scores in general, they're considered to be quite high and across the board women were generally satisfied, but you can see considerably lower scores on the two sub domains.  Okay.  So now I will turn it over to Jenny to talk about some of the work she's done and how the variabilities and VA organizational behavior factors impact MST.

Jenny Hyun:  I wanted to just very briefly about this study and this paper that is in press and will be out very shortly, related to organizational factors related to MST-screening and purpose was to look at--I guess the title says it all, Organizational Factors Related to Screening.  I'd like to call this study an adventure into VA administrative data because we merged five facility-level datasets that we created to patient-level data on MST status, screening status as well age, gender and any previous utilization of VHA services, so we constructed facility data out of the VHA Outpatient Events File, which was essentially a measure of facility size.  We used the ALBCC, which many of you may not be familiar with, but the Health Economics Resource Center has documentation on this data source to look at the amount of resources budgeted to specific areas, such as women's health, that didn't make it into the final analyses, but it was an interesting source of data.  We didn't use the ALBCC to construct a measure of physician-to-patient ratio and we also looked at data on specialized PTSD programs and availability of such in specific facilities.  We used a survey developed by the Women Veterans Health Strategic Health Care Group to look at whether or not there was a women's health clinic at that facility or not and then in 2005 there was this national survey of MST practices that was conducted and we looked specifically at whether or not there was any effect for universal screening MST policy as well as audit and feedback activities conducted by the other facilities.

Our key findings, which are not so surprising, is that many of the organizational factors really didn't come out, except for the  MST practices related to universal screening policy and audit and feedback and we found that those two were significantly connected to the odds of a patient receiving MST screening.  

We also found a significant association for those female Veterans who used the Women's Health Clinic were more likely to be screened for MST than not.  Then I had sort of a pet hypothesis about sort of the diffusion of specialized knowledge from women's health clinics or specialized PTSD programs because these areas are likely to see a higher baseline number of Veterans who have experienced MST.  My hypothesis was that there might be some diffusion that might impact the overall screening level at those facilities with those types of specialized programs, but, unfortunately, the data did not pan out that way and we found no association in specifically women and men--that women who used a facility with a women's health clinic, but who didn't use the women's health clinic per se were not any more likely than women who used the facility that did not have a women's health clinic, so that didn't support my hypothesis.

So in conclusion we wanted just to discuss some ideas for future directions in MST health services research.  This is a very important and exciting time to be doing research with VA administrative data.  So I'm going to hand it back to Dr. Kimmerling to talk about some of those ideas.

Dr. Rachel Kimmerling:  One thing that we didn't mention when we kind of talked about the beginnings of the MST Support Team more broadly--this knowledge and these methods really did grow out of an HSR&D-funded grant to develop methods and do a first-time evaluation of military sexual trauma screening and treatment in VA.  Most of this we owe to HSR&D.  It's really kind of relevant that impactful things can come out of the research that they fund and we're quite grateful.

I do want to give a shout out to Women's Health Research Consortium, I'm sure many of you know has created several interests groups to promote further health services research in women's health and one of them will center on MST and I believe the first Thursdays of the month at noon Pacific time is when we'll be meeting and so I'd love to talk with you all more and collaborate there.

So some of the things that we've been thinking about and that reflect the kind of questions we've been getting lately refer to access to MST-related care.  I think there's a general emphasis on looking at patient-centered access to care across the system and I think there's some unique issues with respect to MST-related care that bear further investigation, especially looking at MST and men and what kind of gender differences there may be.  I think there is so much more to know about processes, care and organizational factors that can really help us implement better detection and treatment for MST across the system and like many mental health conditions the Holy Grail of clinical outcomes--there's a few clinical trials.  I think there's good evidence that our current empirically supported treatments are appropriate and effective for military sexual trauma, but we know relatively little about clinical outcomes associated with MST in other kind of treatment settings, especially for depression, substance abuse and other things and that would be really important knowledge.  So I'd love to learn from you all what you think are important data sources, important research directions and we're happy to answer any questions.

Molly:  Excellent.  Thank you both very much.  I just want to let all of our attendees know--the ones that joined us after the top of the hour, if you would like to submit a question or a comment to the presenters, please use the panel on the right-hand side of your screen, you'll see a row that says questions, just hit the plus sign next to it, it'll expand the box and then you can type your question or comment into the bottom box and press send privately.  We do have a couple questions that have already come in.  So I'll go ahead and get to those now.  The first one: "Is the MST screening conducted at the PVHRAs since many female Veterans do not always enroll in VAMC care or know that they are entitled to VAMC care?"

Dr. Rachel Kimmerling:  I think that's a great question and I think the outreach to individuals who are not yet enrolled in VHA to make them aware of these services is a really important issue.  MST or sexual trauma, in general, is not included in the post deployment health assessments or health re-assessment screenings individuals participate in at discharge, return from deployment.  I think looking at strategies of how to address that would be quite relevant.

Molly:  Great.  The next question we have is another clarification question and I believe you were on Slides around Twenty-five through Twenty-seven when this question came in, so if you want to go back there feel free.  The question is: "Do the stats demonstrate numbers for personnel who experienced one encounter while serving in the military or is it over the course of their life?"

Dr. Rachel Kimmerling:  It's over the course of their military experience.  There's a couple good points in there, one is that VA does not screen broadly for sexual trauma, so we can expect there is probably some population of Veterans who have experienced sexual trauma either before or after their military experience, but it's not during the military, then they're not represented among those captured by the variables that we've addressed and VA's specific screening outreach and free treatment pertain only to sexual trauma during military service.  You've seen the screening questions are quite broad, so we really don't get information on the clinicity of these experiences or the number of times that they've occurred.  It's really one or more experiences in this category during all of military service.  

Molly:  Thank you for that.  The next question: "Is MST tracked by DOD for active duty personnel?  If so, do you access their data for example for trending on response rates to compare active duty versus Veteran response rates?"

Dr. Rachel Kimmerling:  That is a million dollar question.  There's a couple of issues there.  One, as Jenny noted, MST is a VA-specific term, so DOD does have their own surveillance systems for both sexual harassment and sexual assault.  They're treated quite separately among the active duty, so it's quite difficult to compare.  We also have fairly different missions.  Because the DOD is really the setting where these experiences occur, they have a duty to legally prosecute, they have a duty to prevent, as well as treat.  These are historical experiences and we are a health care system, so our priority is just treating the health and mental health consequences when people come to our system.  The thing that explains why they are treated a bit differently in the two systems.  There are some surveillance carried about by the Defense Manpower Data--DMVC Center and they do have some items that don't directly correspond, but broadly track both sexual assault and sexual harassment.  They monitor only the annual incidents, so it's still not really possible to draw some correspondence from VA to active duty kind of prevalence and how folks travel through the system.

Molly:  Thank you for that, the person who posed the question did want to make the side note that they are someone who recently retired from the Army and didn't recall ever being screened for MST at any military facility.  

Dr. Rachel Kimmerling:  I don't believe they are screening in the DOD at this time.

Molly:  Thank you.  The next question: "Are the VET Centers also doing this screening?"

Jenny Hyun:  I believe they are--

Dr. Rachel Kimmerling:  The screening data that we are presenting comes from this Clinical Reminder in CPRS and the VET Centers are not on CPRS, so they are not reflected in our data.  The Vet Centers are, however, a really important resource for MST-related care and the majority of VET Centers across the nation do have designated resources and specially trained providers to treat MST.  So, for those of you that are making treatment referrals and treatment decisions, I'd keep VET Centers in mind, but they are not--individuals who use only a VET Center would not show up in our data.

Molly:  Thank you for that response.  The next question: "Is there a plan to have a universal screening for domestic violence, victimization and perpetration?"

Dr. Rachel Kimmerling:  Well, I think that would be wonderful.  I know of some really wonderful HSR&D supported research.  It's either upcoming or just past cyber seminar on that and I know there's some recently funded work in that area and I think it's important work and it would be interesting to see what comes of it.

Molly:  Thank you and you are correct, we did recently have a cyber seminar in intimate partner violence and people can access that archive by going to the HSR&D Web site and clicking on the cyber seminar catalog.  The next question: "I agree with additional research being needed, non profits are seeing WVs, women Veterans, who are not going to VA and using treatments to address sexual trauma resulting from military service.  The VA needs to look outside VA to see how these programs are being implemented and the outcome."  I'm not sure if you want to comment on that.

Dr. Rachel Kimmerling:  As VA researchers, our mission is pretty much VA health services, but we do have a broad kind of interest in commitment to the well being of women Veterans more broadly, so I would invite kind of any non profit that's interested in us kind of assisting with some evaluation or any research that we could provide and invite them to contact us.  I think that would be wonderful.

Molly:  Thank you.  The next question: "Do current data collection methods separate allegations or harassment and assault?  I heard that they were not separated in the past, can you clarify for current efforts?"

Dr. Rachel Kimmerling:  Do you mean whether the screening separates assault from harassment or are you talking about kind of prosecuted or not prosecuted cases when the individual was in the military?

Molly:  I think we're going to have to ask that writer to write it again and clarify.  She says the former, so I think they're talking about a separation between harassment and assault.

Dr. Rachel Kimmerling:  As Jenny noted, the definition of military sexual trauma put forth in U.S. code includes both harassment and assault, so we do not separate that.  There's been a few studies, for example, some IRT studies and some factor analysis studies about sexual assault and harassment experiences that look at it in great detail and they actually support looking at these experiences as a single factor in the way that we do.

Jenny Hyun:  We should also note that Veterans who disclose that they've experienced MST are not asked to confirm or provide proof that these events actually happened in order to receive clinical services here, that the response to the screen is sufficient.

Molly:  Great.  Thank you.  The next question is in reference to Slide 15, you can feel free to go back to go back there, if you'd like.  "Slide 15 states that ninety-seven percent of men and women Veterans have been screened for MST, is the ninety-seven percent of all Veterans or is it the ninety-seven percent of Veterans who have been to a VA hospital or clinic?"

Dr. Rachel Kimmerling:  That is ninety-seven percent of Veterans who have used a VA clinic consistent with the nexus cohort in Fiscal Year '10.  

Molly:  Okay.  The next question: "Once a Veteran says they have experienced MST can they go back and then change their status to have not experienced it?"

Jenny Hyun:  Yes.  That does happen very rarely, but there are cases where people say yes and then have their responses changed to no.

Molly:  Thank you.  The next question: "You mentioned that providers monitor MST-related mental health conditions, but do not monitor medical conditions, how do we know that women with co-morbid mental and physical health conditions get the medical care that they need?"

Dr. Rachel Kimmerling:  I'm sorry for my lack of clarity there.  The MST Support Team, the five of us here do not monitor medical conditions on an annual basis with the same detail that we monitor mental health conditions, that's because over eighty percent of MST-related care is mental health care and the fact that we are supported by the Office of Mental Health Services, who's, understandably, interested in additional detail about mental health conditions.  If you go to our Web site and look at our--I think three annual reports that are dedicated to MST-related care more broadly, you will see that we do monitor in several ways the non mental health care that is associated with MST.  We just don't aggregate the specific conditions and interpret those data.

Molly:  Great.  Thank you for that clarification.  The next question we have--

Dr. Rachel Kimmerling:  Speaking of future research, if there are medical professionals out there, with the knowledge and expertise to look at that, I think that would be wonderful.

Molly:  Great.  Thank you.  The next question we've received it a couple of times is any of the information in the annual reports available to those outside the VA?

Dr. Rachel Kimmerling:  Not at this time.  If folks outside the VA are interested in publicly available information about MST, please do contact us, we'd be happy to forward on our published papers, there's some good overlap of those reports.  We just don't publish that same paper on an annual basis, of course, so it would be a one-time snapshot.  

Molly:  Thank you.  Next question: "Any idea why homeless Veterans have a higher rate of MST?"

Dr. Rachel Kimmerling:  Another very fertile area for research.  I think there's been some work specific to Veterans and then kind of more generally among homeless women that does point to experiences of sexual trauma, as well as a wide range of inter personal violence and traumatic experiences, as potential factors in homelessness.  I think that would be interesting to look at it, it does, of course, erode one's social support, social resources, fewer opportunities for instrumental support in addition to the mental health consequences that could really impair some ability to maintain employment.  I think there's a lot of potential reasons why there might be an overlap there.

Molly:  Thank you.  The next question: "Can you define the term Clinic Stop 524?"

Jenny Hyun:  Let me clarify for people who are not in the VA or may not be familiar with Clinic Stops, all of the clinics at the VA are identified by a three-digit number and that's in order to track workload, workload productivity and the number of Veterans who are using a specific resource at the VA.  So a while back, in the early days of MST, they started a clinic called Active Duty Sexual Trauma, which is Clinic Stop 524, and they used 524 initially to track how much treatment was being provided for military sexual trauma, since then, however, MST programming at VA facilities and our understanding of MST and the clinical conditions related to MST has grown substantially and 524 is not adequate--one clinic is not adequate to capture the breadth of services that are delivered across VA facilities related to MST.  So the strong recommendation is not to use 524 at all to monitor MST-related care.  There is still some confusion out there that 524 does capture MST-related care, but we mention it here specifically to say that it does not.

Molly:  Thank you.  I do see that we're at the top of the hour, but we have several more questions.  Are you two available to stay on and continue answering questions?

Dr. Rachel Kimmerling:  Sure.

Molly:  Great.  Thank you.  We do try and stay on and get them on the recording, so that if any of our attendees have to leave, they can just view the archive, to hear the rest of the answers.  The next question starts out with a comment, "Our own research has found that women Veterans often do not report their initial trauma or seek care until years after their initial trauma or MST event, how can we, as researchers and clinicians be confident that Veterans are given the opportunity for such events to be shared and be directed to treatment, if needed, if screening is only done once?"

Dr. Rachel Kimmerling:  I think that's a great question.  I think one of the wonderful things about screening, although it emerged specifically for eligibility purposes is that we do know that individuals who have experienced traumatic events, specifically stigmatizing events such as sexual trauma, rarely spontaneously volunteer that information and it's much more effective to ask folks, but we do know--while we do find the overwhelming majority of positive responses to the MST screen do occur on the initial screen, we do know there are cases that are not uncommon when a Veteran will wait till the context of a trusting clinical relationship to disclose this.  That's one of the reasons why we really try to disseminate as strongly as possible methods for changing the Clinical Reminder status, so even if Veterans deny or in cases where they decline to respond on screenings and it's important to know that those Veterans are screened more than once if they decline, then we come back in a year, so there are cases, but we do encourage clinicians to change the Reminder status so that person is subsequently eligible for the expanded access associated with MST.

I also cannot state emphatically enough the excellent work that the Education and Training Division of the MST Support Team does, to really encourage awareness and clinical expertise among such a broad range of mental health professionals in VA.  So that even if it's not a standardized Clinical Reminder screening, I really do see the capacity growing and growing for mental health professionals to really sensitively be aware of these issues and address these with patients in the context of their relationship.  So we really don't let folks kind of slide under the radar.

Then when you think about screening more than once, it's important to remember that among women Veterans, maybe twenty to twenty-two percent of them will respond positively to a screen, perhaps a few percent more will respond negatively and then change their status, but consider the other eighty percent that did not experience military sexual trauma, who you'll be re-screening unnecessarily, they represent the majority of the population, so that clinical efficiency of universal multiple screenings is really not supported and unlikely to be implemented, but I think really sensitive clinician judgment and targeting this in high frequency settings and our being aware of it can really do a lot.

Molly:  Thank you very much.  The next question: "Among the 5,758 women in the Satisfaction Analysis, what percent is for MST positive?"

Dr. Rachel Kimmerling:  The proportion of women with positive MST screens in that sample didn't significantly differ from our national averages, so I'd tell you somewhere in the neighborhood of twenty percent.

Molly:  Great.  Thank you.  This is a comment that came in when we were speaking about the Vet Centers: "I am a Vet Center employee and we do ask the female Veterans that come in the Vet Center if they have any concerns with MST?"  Thank you for that.

Dr. Rachel Kimmerling:  That's wonderful.

Molly:  Next question: "Does any of the data reflect the Centers located in the southeast region, specifically in Georgia?"

Jenny Hyun:  Our annual reports on MST screening and treatment are at the facility level, so all of the VA facilities across the nation are reported in there, including the ones in Georgia.

Molly:  Thank you.  The next question: "Dr. Hyun, is correct with her information, the VAMC does make referrals to the Vet Center with MST clients and vice versa."  So thank you again for another clarification on that.  Next question:  "Males are screened as well, MST is listed as an eligibility requirement for our services."  Thank you.  Lots of comments coming in.  "Have you considered partnering with other federal agencies that address women health issues?"

Dr. Rachel Kimmerling:  I'm wondering if that person is still on the call, if they could provide us a little more information on what kind of partnering they're thinking of.  There are really wonderful kind of resources out there amongst federal agencies for women's health and we do find each other at conferences and meetings and other resources.  It's very helpful for the work we do.  We'd be happy to address that more specifically if someone had thoughts.

Molly:  Thank you.  That person is still in the meeting, so I invite her to write in with further information.  Next question: "Could you define what a nexus clinic is?"

Jenny Hyun:  Those are the clinics that are identified by the Office of Quality and Performance as clinics where it is acceptable and expected for a provider to screen for MST, as well as that they are also expected to conduct other types of performance measurements, types of screens.

Dr. Rachel Kimmerling:  When I think about this issue, I--just to provide an anecdote that illustrates it for folks outside the VA, I think of my grandfather who is a Veteran, but sees his care in another health cares more convenient to where he lives, but VA really has some bargains on hearing aids and given his eligibility and benefits, it really makes financial sense for him to get his audiology care at the VA, which, of course, he sees as excellent.  He's very happy with it, but it wouldn't make sense to screen him for a variety of conditions when he doesn't receive the majority of his primary care, even his medical specialty care at the VA, and we wouldn't expect someone in audiology to be especially proficient in screening for sexual trauma.  So we limit our screening to very broad groups of primary care kind of medical specialties that often substitute for primary care, such as maybe cardiology and diabetes clinic and then mental health settings, where it just makes more operational sense to screen.

Molly:  Thank you.  We are getting towards the end of the questions and I just want to thank you both for staying late to do this.  "Do you know what is the percent of minority women that have experienced MST, Latino, African-American, Asian, et cetera?"

Jenny Hyun:  We don't report that on an annual basis.  I believe that there is some research literature that has looked at some of the racial ethnic breakdowns, but I don't know have that at my fingertips.

Dr. Rachel Kimmerling:  But, ma'am, if there's anyone out there with a good rates variable from VA administrative data for the recent years of women Veterans, please, please give us a call because we'd love to look at that.  That's it for those of you outside the VA, looking at race and ethnicity from VA administrative data is quite difficult [inaudible] due to the high rates of missing data, so it can often be hard to reliably report race and ethnicity.

Molly:  Thank you.  The person who wrote in about collaborating with other government agencies, they suggested perhaps establishing a regional roundtable discussion and/or Webinar series with state and local organizations.  Thank you for that input.  

Dr. Rachel Kimmerling:  Yes.  That's very interesting.

JY:  That's a wonderful suggestion.  We'll keep that in mind.

Molly:  The next question: "How many nexus clinics are located in the south?"

JY:  That's a clarification question.  The nexus clinics are specific to the medical centers.

Dr. Rachel Kimmerling:  For example, a primary care clinic is one of the nexus clinics.  So every VA CBOC provides primary care virtually, so it just excludes kind of a smaller number of specialty clinics.  Another example would be some Veterans receive care in other settings, but come to VA for pharmacy only because our drug prices are lower than Kaiser.  In many cases, again, we wouldn't want someone working in the pharmacy to be screening for MST.  They're not the population of a regular user that would be likely to use our services, but every VA clinic has sufficient primary care and mental health services for us to reliably monitor MST screening and treatment.

Molly:  Thank you for that response.  The final question we have: "Of those Veterans who are screened to be positive any data on how many are actually treated?

Both say yes.

Dr. Rachel Kimmerling:  As a matter of fact on Slide 25, I believe, have the treatment rates aggregated by gender.

Jenny Hyun:  Are the treatment rates for those Veterans who use the VA facility in Fiscal Year 2010, how many of those went on and used MST-related services during the year?  We report that on an annual basis.

Molly:  Excellent.  Thank you both very much.  In these last few moments, do either of you have any concluding comments you'd like to make?

Jenny Hyun:  No.  We thank everyone for their attention and for the wonderful questions, for the opportunity to discuss in detail VA administrative data on MST. 

Dr. Rachel Kimmerling:  Yes.  Thank you so much for having us and thanks for your interest in this topic.

Molly:  Great.  Well, we appreciate you taking the time.  I didn't read all the comments aloud on the call, but there were many people who wrote in and said this was an excellent and very informative presentation.  Also I would like to take a moment to plug our next women's health cyber seminar, which is taking place on Monday, the twenty-third, also at one p.m.  It will be presented by Dr. April Gurlock and Dr. Jackie Grimacy and the topic will be: From Highly Distressed to Thriving--a Qualitative Analysis of Relationship Behaviors in Veterans with PTSD.  So I invite our attendees to join us for that.  You can register in the cyber seminar catalog.  So thank you again to Rachel and Jenny and this does formally conclude today's HSR&D cyber seminar.

Jenny Hyun:  Thank you very much.

**[End of Recording]**

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