MANAGEMENT BRIEF

Number 16 Overviews of Health Care Topics for VA Senior Managers August 2000

Women Veterans’ Health Care: Closing the Gender Gap

“A greater number of women in the military and the resulting increase in female veterans enhances

the need and sharpens the focus for research on women’s health issues.”

John G. Demakis, MD

Director, Health Services Research and Development Service

Why the renewed focus on women veterans’ health care?

Women constitute one of the fastest growing segments of

the veteran population. In 1992, women made up 4.4 percent

of the total veteran population; currently, they represent 16

percent of our active duty military. With the increased number of women in the military came an awareness of gaps in

their health care. A few studies conducted in the early 1990s

suggested that inadequate provisions were made to accommodate the needs of female patients. Also, a 1993 Congressional

hearing identified long-standing problems in providing quality health care for women veterans, while also presenting evidence of strong support within VA leadership to correct those

problems.1

 In an effort to address the concerns, VA enhanced

and expanded its research in women’s health. For example, in

FY99 funding for women’s health research at VA totaled almost $22 million, with VA providing about 30 percent of the

total dollars. These research dollars supported 250 research

projects relevant to women’s health in areas such as aging,

breast cancer, reproductive health, mental health, substance

abuse, and the delivery and organization of health services.2

What are some of the unique research issues related

to women veterans?

Some diseases or conditions are unique, more prevalent, or

more serious among women, and women veterans in particular,

and some may present risk factors or require interventions that

are different for women. A few of these include breast cancer,

osteoporosis, ovarian cancer, reproductive health, and sexual

and other forms of post-traumatic stress disorder (PTSD). More

attention is also being directed at gender-specific utilization of

VA health services, issues of access, and any barriers to care for

women veterans. All of these issues, in addition to developing

better information on the demographic characteristics of women

veterans and their health status and health needs, require special

research consideration.2

What has VA done to enhance health care for women

veterans?

Over the past decade, VA has taken steps to ensure quality

health care for female veterans. For instance, VA established

a women veterans’ coordinator in every VA facility and

instituted women’s clinics that provide gender-specific preventive care. VA also developed special counseling services

for women with PTSD, and for those who experience sexual

trauma. In addition to increasing specialized services that

address women’s unique health concerns, such as mammography, VA created eight comprehensive women’s health centers, increased specialized training on women's health care

issues, and expanded research that focuses on women's health

care issues.1

How is HSR&D working to improve health care

for women veterans?

In 1994, HSR&D implemented a special initiative on

women’s health that included development of a national registry of women veterans – the first electronic database of

women veterans. In 1997, HSR&D also initiated a special

research solicitation related to exploring gender differences

in health care and improving health services for women

veterans. Six studies were funded under this solicitation between 1997 and 1999 related to PTSD, sexual harassment,

depression, alcohol abuse, and surgery risks and outcomes.

In FY99, HSR&D funding for these six studies and additional research specifically focused on women’s health totaled over $1 million.2

 HSR&D is conducting research

specifically related to women's health concerns so that VA

can continue to improve the quality of care afforded to

women who have served their country.

VA HSR&D Management Brief August 2000 Page 1 of 3
VA HSR&D Management Brief Number 16, August 2000 Page 2 of 3

Risky health behaviors and poorer health status

may predict post-surgery morbidity and mortality

An HSR&D study was conducted to examine relationships

between patient sociodemographics, preoperative risk,

and clinical outcomes of patients undergoing surgeries at

VA medical centers. Using information collected from VA’s

National Surgical Quality Improvement Program (NSQIP),

investigators identified all mastectomy procedures and hysterectomy procedures performed at VA facilities between

October, 1992 and September, 1997. Any hospitalizations

that occurred within one year of these procedures were noted,

while complications were defined by an expert panel of

surgeons.

Over a six-year period, 1,333 mastectomies (60% female,

40% male) and 1,758 hysterectomies were performed in VA

facilities. For both men and women who underwent mastectomies, within 30 days of the procedure, 8 percent experienced

one or more of the 21 complications defined by the NSQIP.

Nine percent of the women who had a hysterectomy experienced one or more of the 21 complications defined by the

NSQIP. Investigators then identified preoperative patient variables that increased the probability of morbidity and found

that risky health behaviors (i.e., smoking, alcohol use) and

poorer health status (e.g., presence of disease such as diabetes

or cancer) prior to surgery may be significant predictors of

increased 30-day morbidity.

Women veterans account for less than 5 percent of all

VA health care users, thus the rate of female-specific

procedures at any one facility is low. This study will help

inform VA about the women who undergo procedures, their

outcomes, and how this information compares to the non-VA

health care sector.

Hynes D, Weaver FM, Ippolito D, Cull W, Thakkar B,

Gibbs J. Quality of care for mastectomy patients treated in

VA hospitals: Results from a National Study. Association of

Health Services Research 16th Annual Meeting Abstract

Book. 1999.

Weaver FM, Hynes D, Ippolito D, Thakkar B,

Cull W, Gibbs J. Characteristics and outcomes of women

undergoing hysterectomy in VA facilities. Association

of Health Services Research 16th Annual Meeting

Abstract Book. 1999

HSR&D, study #GEN 97-016

Study suggests different resources needed

for women veterans’ health care

As the number of women veterans seeking VA health

care continues to increase, it becomes more important to

identify any special service needs or disparity in care for

this patient population. A recently completed HSR&D

study identified factors that may affect health-related quality of life for women veterans using VA ambulatory care.

This study surveyed over 4,000 women veterans concerning six domains: health status, military service, medical

conditions, use of health care services, social support and

life experiences. Findings showed that women reported

consistently low scores on health-related quality of life

across multiple domains, reflecting considerable health

care needs. When compared to men, women scored lower

(indicating worse health) on emotional and social functioning domains but had higher scores for physical functioning

and general health perceptions. Also of importance is the

finding that 23 percent of the women veterans in this

sample reported experiencing sexual assault while in the

military, and more than half (55%) reported sexual harassment while in the military. The findings from this report

have significant implications for VA clinicians who treat

women and for policy makers who determine future allocations for health care. In particular, they point to the need

for expanded mental health services and screening for

sexual assault for women veterans.

In June (5–9) 2000, this study’s Principal Investigator,

Katherine M. Skinner, PhD, a VA HSR&D researcher at

the Center for Health Quality and Economic Research in

Bedford, MA, presented findings from the VA Women’s

Health Project at a United Nations’ Special Session devoted to assessing progress over the last 5 years in meeting

the goals of the Platform for Action for Gender Equality,

Development and Peace for the 21st Century.

Skinner K, Sullivan L, Tripp T, Kressin N, Miller D,

Kazis L, Casey V. The health of women veterans who use

VA health care: Results from the VA Women’s Health

Project. Women & Health 1999; Vol. 29.

Kressin NR, Skinner K, Sullivan L, Miller D, Tripp T,

Kazis L, Frayne S. Patients’ satisfaction with VA health

care: Do women differ from men? Military Medicine.

1999; 164:283-288.

HSR&D, study #SDR 93-101

There is a significant amount of ongoing and planned VA research on women’s health care issues.

Below are recent findings from a few HSR&D studies that focus on important issues

 related to the health of women veterans.
For more information about this issue of

MANAGEMENT BRIEF, or to send comments, contact:

Gerry McGlynn, M.Ed., MDRC, Manager,

Information Dissemination Program, 150 S. Huntington

Avenue, Boston, MA 02130. Phone: 617-278-4433.

Fax: 617-278-4438.

Visit the Research and Development web page at

http://www.va.gov/resdev or the Intranet site at

http://vaww.va.gov/resdev, or utilize the MDRC

Fax-on-Demand system at (617) 278-4492 to see

additional MDRC publications and reports.

This is our sixteenth MANAGEMENT BRIEF. Please fax us your

suggestions and comments:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Name: ____________________________________________________________

Title: ______________________________________________________________

Phone: ________________________ Fax: ____________________________

The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within VA’s Office of Research &

Development, Health Services Research & Development Service. The

purpose of the MANAGEMENT BRIEF is to provide VA senior management

with a concise and timely overview of a specific health care topic that

includes topic definition, benefits, VA research activities, and resources

for further information.

An assessment of alcohol screening

questionnaires for women

Rates of life-time alcohol abuse or dependence among

women in primary care settings range from 23 to 25 percent,

and 9 percent of women who seek primary care have had

alcohol-related problems during the past year. However,

women with alcohol-related problems are half as likely as

men to have received any alcohol-related treatment. In addition, women seeking specialized treatment have more severe

alcohol problems than men do, suggesting delayed treatment.

Women also appear to be more susceptible than men to the

medical complications associated with alcohol use, such

as increased mortality, cirrhosis, and breast cancer. Brief

primary care interventions can decrease heavy drinking and

alcohol-related morbidity, thus screening programs that identify women who drink heavily are vital.

This HSR&D study sought to describe the performance

of alcohol screening questionnaires in women patients.

Investigators reviewed published, peer-reviewed studies

from 1966 through July 1997, which focused on screening

questionnaires used in the general clinical population. Investigators then compared data regarding men and women, as well

as women from different ethnic and racial groups. Results of

this literature review show that the CAGE, AUDIT, and

TWEAK questionnaires were the optimal tests for identification of alcohol dependence. However, despite the diverse

settings and methods of the studies included, all three

questionnaires were more sensitive for alcohol abuse and

dependence in studies of black women than of white women.

In addition, the TWEAK questionnaire may perform better

than either the CAGE or the AUDIT questionnaires in

white women.

While screening is only the first step in the process of

alcohol abuse assessment, the optimal screening measurement

tool will increase the number of women who receive further

diagnostic assessment and thus are referred for appropriate

alcohol treatment.

Bradley KA, Boyd-Wickizer J, Powell, SH and Burman ML.

Alcohol screening questionnaires in women. A critical review.

Journal of the American Medical Association 1998;

280(2):166-171.

HSR&D, study #GEN 97-022

Toward gender awareness

Despite VA efforts to better accommodate the health care

needs of a growing number of women veterans, an historical

orientation toward treating male patients may have resulted

in a less than optimal care environment for female patients.

This three-year HSR&D study seeks to develop a reliable and

valid self-report instrument to measure gender awareness that

could be used in all VA facilities.

In the first two years of the study, 488 VA employees, who

were randomly selected from the VA New England Health

Care System, completed the gender awareness assessment

instrument. Initial findings indicate that it demonstrates suffiVA HSR&D Management Brief Number 16, August 2000 Page 2 of 3

cient validity to be used as an instrument to measure attitudes

toward women veteran patients and sex role egalitarianism.

This gender awareness assessment instrument will provide

a means to identify and measure factors that contribute to the

quality of VA health care for women veterans and will provide a mechanism to pinpoint training needs for the education

of VA employees. Further, the instrument will afford a means

to monitor organizational improvements in gender awareness

over time.

Miller PM, King LA, Wolfe J, King DW. Gender ideology,

sensitivity, and knowledge: A model of gender awareness in

VA health care. Veterans Health Systems Journal, in press.

HSR&D study #PPR 94-001

References:

1. Investigator-Initiated Research Major

Research Priorities for Fiscal Year 1998.

http://vaww.va.gov/resdev/ps/pshsrd/1297010.htm.

Updated 3/4/99.

2. Research on Women’s Health at VA FY1999.

Jay Freedman, unpublished internal report.