**Introducing the VA Women’s Health Research Consortium**

>> And we are approaching the top of the hour.  So at this time, I would like to provide the introduction for Dr. Yano who will be presenting for us today, she will be introducing the VA Women’s Health Research Consortium.  Dr. Yano is trained in healthcare epidemiology, biostatistics and health policy at UCLA and Rand Health.  Dr. Yano has 25 years experience in health services research and program evaluation.  She currently holds the position of co-director and research career scientist at the VA Greater Los Angeles HSR&D Center of Excellence for the Study of Healthcare Provider Behavior and she is also adjunct professor of Health Services at the UCLA school of Public Health and currently serving as the P.I. for the Women's Health Consortium.  I would like to turn it over to you, Dr. Yano. 

>> Thank you very much, Molly.  Am I controlling the slides? 

>> Yes. 

>> There we go.  At the very end.  Not a problem.  I'll scroll it up.  There we are.  Thank you so much.   And thank you for that lovely introduction.  And welcome, everyone.   

As many of you probably know, and for those of you who don't, there are many more women serving in the military today than in prior conflicts than over the history of the U.S. U.S. armed forces.  And we're finding now those that are serving the military are as many as 20% of new recruits, and many of those that are coming out of and returning from Iraq and Afghanistan are entering V.A. care at unprecedented levels.  Last estimates I heard were between 48 and 50% market penetration among women veterans coming back from those conflicts seeking V.A. care.  At this juncture, V.A. clinicians have historically been in a male-dominated healthcare system and V.A. clinicians are now learning to care for twice the number of women as they did a decade ago, and in -- this is in context that is creating an increased demand for research to inform evidence-based policy, a practice in policy to ensure best possible care that we can deliver. 

I wanted to give you an abbreviated history of the investment that V.A. has made in women's health research, and it starts really to varying degrees back to 1983 when, at the bottom of this arrow, you will see the V.A. mandated all research studies include women veterans consistent with what happens for NIH and other government-funding agencies.  The V.A. is not a funder per say but provides intramural resources to V.A. investigators.  By '92, there was an early V.A. women's health research agenda setting process that was begun using NIH criteria.  Within another year or so, there were the first early women's health studies that began in the V.A. that were looking at their needs, variations in their care and gender or sex differences in the receipt of care and the prevalence of different conditions.  The first V.A. health services research and development women's health solicitation started in 1996, and funded three service directed research studies or SDRs and within another couple of years, they funded another women's health research solicitation demonstrating their commitment to this area of research and funded about five studies in that particular round.  Third solicitation came out a couple of years later and also some of the first women's health focused career development awardees or CDAs were funded. Many are full professors and leaders in their own right, mentoring the next wave of researchers in this area.  By 2004, the V.A. HSR&D oversaw the development of the office research and development wide research agenda, including biomedical, rehabilitation, clinical and health services research.  They also funded the first systematic review of the literature on research among military women and women veterans. They began to staff the women's health Scientific Merit Review Board, or SMRB, and they funded a special issue in the Journal of General Internal Medicine, or JGIM, on the healthcare of women veterans, which came out – published - in 2006 and started an interest group.  By now, the portfolio has continued to increase.  Last summer, and I'll talk about this more later in the talk today, HSR&D funded a Women's Health Services Research Conference, funded the Women's Health Research Consortium that I'm going to talk to you about today and the practice-based research  network, as well as a longitudinal study of women veteran's during the Vietnam war.  

Now, part of the original research agenda that came out in 2004 and was published in 2006 were a series of goals for fostering more research in this area.  And part of the goals from that conference at the time were to identify the research priorities and address them, which HSR&D did through putting forward those solicitations I mentioned a moment ago, to build the office of research and development capacity in women's health research through improved networking, better collaborations and mentorship, and there I provide you with one of the websites that describes some of the information about the capacity-building efforts.  Also, to address methodological  limitations and other barriers.  There were people that were part of the original planning group for the women's health research agenda setting effort who indicated that if you didn't enhance scientific review by including an increased number of women’s health researchers and experts in the field, that the field simply would not change. Fortunately, HSR&D responded by providing that better integration of expertise. There were also additional, not only women's health but a deployment health solicitation, and that is important because of the high proportion compared to prior wars of women veterans in the conflicts in Afghanistan and Iraq.  There has also been -- there was a push for increasing the visibility and awareness the V.A. women’s health research, which I mentioned was through the special issue of V.A. women's healthcare issue that came out in 2006.  We started a listserv, increased collaboration and mentorship and went through this increased participation in the interest group. 

I wanted to make the first point here about the growth of the women's health research literature.  And there -- we had the first systematic review that was indeed published in 2006 and you can see the substantial growth in the amount of literature published on women veterans.  The JGIM articles represented about 14 of the studies and you can see the tremendous growth thereafter.  In a systematic review led by Dr. Bean-Mayberry of the VA Greater Los Angeles that was published last year, she found there were more papers published in the last five years than the previous 25 years combined.  So, we have a lot to be proud of and a lot more information about military women veterans available that has been available previously.  Now, I wanted to give you an idea of the kind of growth we have been experiencing.  Back in the 1990s, when much of the research was going, there were just a couple of handfuls of investigators who were either at least interested in women's health research within the V.A. or actually were among those first to get funded.  By this time of our agenda-setting conference in 2004, you can see that the numbers increase substantially.  This is where we are today.  We have over 150 MD/PhD investigators across the United States who have indicated they're either currently involved in some kind of quality improvement research or other kind of research trial, or observational or descriptive studies going on now or are interested in doing so in the near-term.  So, we have the numbers of potential principle investigators, but most investigators in the past still continue to exclude women from their studies.  Indicating there are too about too few of them, they're on average 6 to 7% of the number of veterans we see in an average practice or facility across the country, or too hard to recruit.  They may or may not be in the standard primary care clinic or in enough numbers to easily recruit them.  Some indicate they can't recruit enough of them to look at by gender.  When they submit grants, they will indicate they will recruit them to the extend that they're available but -- extent they're available and may or may not put in special efforts to ensure they have enough to look at subgroup differences.  Or some investigators are not interested in gender or sex differences, and it becomes not a focus of their research or too difficult to get the additional resources to recruit enough women as well.  Some actually don't understand their healthcare needs, some don't understand how they use V.A. healthcare and those are things we can resolve.  In the past, they had trouble getting V.A. women’s health research published.  As you can see from the trajectory of the publications I showed you a moment ago, I think we have gotten over the majority of the hurdles.  

Now, this I have to give courtesy credit to Dr. David Atkins who runs the VA quality enhancement research initiative program, and I enjoyed his slides.  I think they would make an important point for V.A. investigators.  This is, researchers are from Mars and managers are from Venus.  Our managers usually say, “why don’t researchers study the problems I need help with?” And as investigators, we say “why don't healthcare managers pay attention to my research?”.  The opportunity we have as researchers in the V.A. is to have a direct impact on practice and policy.  And see we -- it behooves us to understand how to try and communicate the kinds of things that we can do and for us to have a better understanding of what the research, the managers and policymakers need in terms of information, and I would posit that we're never going get over the quality chasm in healthcare if we don't improve these research clinical partnerships.  So this I need to give courtesy credit to Steve Asch, who has been the research coordinator/director of the quality enhancement research initiative for HIV.  After 10 or more years of doing research in the area of HIV screening, he gave the wonderful example of handing off the wonderful research evidence to a central office leader and saying here we go, this is our New England journal articles, our JAMA articles and we know all these things work.  I hope you're going to put this off into national policy and practice. The problem is, it didn't work. To his surprise, the leader basically turned around and said, you know, you're delivering a dead mouse.  And he was not too thrilled with that response.  And indicated that to please explain this quandary further.  They said, you know, you have been working with this and playing with this dead house mouse for a long time now, and it's published in these wonderful places.  But the evidence that you're providing is not alive enough.  Isn't useful enough for policy and for practice for me to know exactly how to take this and change practice as we move into different kinds of V.A.'s or different regions of the country.  So, this will help us get a better understanding of the different perspectives, priorities and pressures we as researchers have.  We have our timelines and, obviously, the expectations differ for what we're supposed to be getting out of our research studies, the time it takes, the institutional review board approvals, we have to wait for the hiring processes and then the publication at the other end.  Our managers don't have the luxury of wait and see and there is a very important part of the research that we do that requires the research clinical partnership.  So, there is a substantial need to accelerate the impacts that we're having in all V.A. research, and in women's health research as well.  The researchers we found may not have enough training in clinical or health services research trials, let alone implementation science in order to accelerate the impacts of their work.  The majority of the literature I mentioned a moment ago is still descriptive and observational and many researchers need training on how to get to interventions, how to design them, how to integrate the literature and how to move forward in getting into the field.  There is also not enough information to adapt interventions to the circumstances of women veterans.  They have different experiences, different patterns of use, co-morbidities, healthcare needs, different expectations and sometimes different trusts in terms of how the healthcare system approaches them.   One example is TIDES, I know the V.A. loves its acronyms as we do.  That stands for Translating Interventions for Depression into Effective care solutions and that is based on over 35 randomized trials of evidence on how to deliver depression collaborative care in primary care settings.  This is part of an evidence-based that has been integrated into national V.A. policy for primary care mental health integration as one of the key evidence based care models for implementation.  And yet unless women use primary care practices where TIDES is implemented, they're unlikely to actually experience the benefits of care of this evidence-based care model.  Currently to our knowledge, it's not used in women's clinics delivering primary care, nor has it been adapted to address comorbid post-traumatic stress disorder and/or military sexual trauma.  Inclusion of women, as I have been saying before, has been required and so we also need to market to, and educate the broader research community to give them tools in which to be successful in this arena.  

So, the V.A. Women's Health Research Consortium was developed to help implement these needs.  Our  aim is to help research transform V.A. care and is to to specifically arm the many investigators I mentioned before with the knowledge, skills, and collaborations necessary to generate the scientific knowledge, to help them develop evidence-based care models and interventions, to help them understand the strategies for transforming V.A. care for women and through improved research clinical partnerships, and also to help V.A. HSR&D meet the health research performance measures.  Our approaches for doing so include providing methodological and content-related education and training through cyberseminars, for example, like this one today, to build the capabilities and collaboration across the 150-plus people that are interested in engaging in this kind of research, to provide technical consultation, to provide mentorship or identify mentors in your local facilities or V.A. networks, and to establish communities of practice around topical areas of interest.  We also want to help continue to accelerate the dissemination and implementation of research into practice. 

The Consortium is part of a larger V.A. women's health research network.  And so, we have the Women's Health Research Consortium and the Women Veterans Practice-Based Research Network. Today, I'm just going to focus on the Consortium activities and we'll have Dr. Defresne from the V.A. Palo Alto Healthcare System and Stanford University present about the practice-based research network on another day.  I do want to give you at least a little bit of information about the practice-based research network on the right-hand side of the slide.  It's comprised currently of four initial core sites: Palo Alto, Iowa City, Durham, and Los Angeles, with the coordinating center at for the research center at Palo Alto.  And that network will enable us to conduct a series of implementation evaluation projects that will test our ability to collect data from patients, providers, and to conduct organizational implementation studies while we identify new projects that can use that infrastructure.  Those same four sites are also the foundation for the Women's Health Research Consortium, but the consortium hub in this situation is Los Angeles.  And up in Palo Alto, we have economics and database expertise.  In Iowa City, we have post deployment health research expertise.  We have clinical trials expertise at the Durham V.A..  And in Los Angeles, we have extensive expertise in health systems delivery issues, quality improvement research and implementation research.  In addition to this, we have a relationship with CIPRS, the Center for Implementation Practice and Research Support led by Dr. Brian Mittman to ensure that we provide educational opportunities and collaboration and mentorship in implementation science. The hub at this time provides technical capabilities and statistics, qualitative methods, survey design, institutional review board, as well as central IRB consultation and implementation science. 

Our target audiences for the kind of work we do are numerous as you might imagine, in trying to put forward and support and foster research clinical partnerships.  So we work with the V.A. central office leaders, as well as selected VISN directors and other staff, and the VAMC’s to help them move forward in some of their missions related to evidence-based care delivery.  We also, obviously, have a direct interest in setup of the stakeholders of the V.A. women’s health researchers themselves through intervention, consultation and mentorships, and there are a whole host of other V.A. established researchers who need to be educated in the basics, need to be connected with people who have expertise in women's health in the V.A., and to whom we should market the practice-based research network so women have an opportunity to participate in the wide range of interventions being under studied in the V.A.  And then there are also the front-line clinicians who have enormous experience in delivering care to women veterans and to whom we can provide quality improvement research training, help them connect to researchers so they can begin to collaborate and see if they can collect data about and solve some of the issues they see in routine practice. 

Just to take you through briefly, some of the kinds of Consortium activities.  In the top group here, over 150 V.A. women's health research interest group and listserv members.  With any group of people, they have quite a variation in terms of their research experience and we want to be able to make sure we provide activities through cyberseminars, consultation, and other activities that meet their respective needs.  Some will require very intensive and sophisticated implementation research training, perhaps they're ready to go from secondary analyses to big multisite clinical trials, and we aim to help them work through some of those issues.  The same thing with folks with medium to low experience.  They may need mentorship, they may need basic skill building, or career development guidance to extend their interests into reality.  And the second box here is on the general HSR&D investigators who we want to be able to arm with the ability to add women veterans or to generate the new women's focused research proposals.  The kinds of information the Consortium will develop for this group will be somewhat different, in terms of making sure they understand the women's veterans healthcare issues and that delivery and organization of care so that they can design studies in an appropriate manner.  The V.A. clinicians, we feel that from a bottom-up quality improvement research perspective, we want to make sure their voices are heard and that we provide them with the kinds of supports that are important for their moving forward clinically and professionally. 

Sorry for the slight graphics change here but basically, to give you an idea of how we're operating here, you can see we have actually -- are conducting investigator and clinician-needs assessments and we have a nationally premier steering committee comprised of both senior researchers, research program directors from V.A. central office as well as women's health research, women's health program leaders for the clinical side of health.  We use that to prioritize our training activities and consultation activities and to segment the market, if will, and strategically plan for meeting the needs of that large group of individuals we have been discussing. 

Our primary tools for doing this will be through the cyberseminars, through one-on-one or group consultations, small groups, as well as web tools that we're beginning to develop in the topics as I mentioned here: in skill building and career guidance, education on women veterans, mentorship and collaboration, intervention development where we hope to spend a bit of our time and energy, the development of multisite intervention trials and then moving to implementation and quality improvement research. 

To accomplish those goals, once we build the capabilities in the field increasingly, we want to be able to help market the practice-based research network capabilities to ensure that people do include women at a greater level and for those sites that have very high volumes of women veterans and we anticipate increasing the number of sites over time any that are part of the PBRN.  We provide scientific review early on for the grants before they get submitted to try to ensure they have the technical information that is necessary, as well as hooked into the resources that they might need from other investigators.  We're hoping to foster more collaborative networks of people.  I think that is one of the best things I know of about V.A. research is not just the fact that we can have an influence on evidence-based practice and the front lines, but that we're a remarkably collaborative group of people.  I know few centers that don't have principle investigators and co-principle investigators at any number of other sites across the country in service of improving the care for women veterans and other veterans as well.  We want those collaborative networks to move forward to increase quality improvement research and implementation and hopefully have greater impacts.  We'll then feed back to what our steering committee recommends as priorities moving forward. 

And I wanted to mention briefly for those of you who may not be familiar with this notion of a research to practice pipeline.  It has an important impact on the kind of work we want to do in women veteran's health research.  By now, NIH has moved beyond T-1 and T-2 as you see there, to T-1, T-2, T-3, and T-4.  So let me give you the simpler version for now.  The basic biomedical research is quite substantial in the V.A. as it is in the National Institutes of Health.  Much of the work that gets from the basic sciences to clinical science and knowledge, requires a translation to human studies which, many people started off with calling T-1, translation first step.  To get to health services research, which is the kind of research I do, the kind of research that the Consortium is starting off with and providing support to, really moves us from efficacy studies, the ideal practice, the ideal homogenized group of people to effectiveness research, where you are trying to figure out how to take something to scale and how do you move it through different kinds of V.A. practices, how do you take it to different kinds of patients.  This is the really the domain of health services research.  Now to move an effective trial or effective piece of evidence from a health services research study to implementation research, requires inquiries about adoptions, implementations, spread, and sustainability.  And this shift to T-2 research, which requires interventions at the practice and multipractice level, requires the ability to document and diagnose gaps and test new implementation strategies, underlined with those, organizational and provider individual theories is an emerging and rapidly growing area of research.  And as you can see, the funding is kind of related to the box sizes, although I would say the basic biomedical research box is -- would probably burst through this particular pipeline, compared to the amount of funding provided implementation.  It is implementation research that is the kind of work that helps us understand what the changes in routine care processes, and outcomes are.  And so, it's one of the reasons why we're focusing on the health services research and implementation boxes here.  The research implementation pipeline is described quite well by the V.A. QUERI program and CIPRS as I mentioned before.  And as you can see, within the interventional, the yellow pipe in the middle, the interventional and implementation studies really comprise four phases of research.  They start with small pilot projects, typically a single site, single clinic, to phase 2 small scale efficacy trials, to phase 3 large scale effectiveness studies that might be multisite, to phase 4 adaptation, adoption monitoring, and refinement, when you're starting to change the system of care.  From our understanding of the portfolio, most of the V.A. women's health research is at what we call QUERI step 2, 3, and 4.  They're still at the effectiveness and systematic review and observational review levels - the two orange or reddish-orange pipelines to the left - with a couple of notable exceptions, including the randomized trial of post traumatic stress disorder treatments among women veterans that Dr. Paula Schnurr led, and the gender sensitivity curriculum trial that Dr. Don Boat led. 

So, let me transition some to some of the actual activities we have set up already within the research Consortium.  The spotlight on women's health cyberseminars that you have hopefully been enjoying the past six months or so, are a direct product and organized by virtue of Consortium members.  We're trying to map to the different target audiences I mentioned before, providing methodology seminars and advanced methodology seminars, research highlights, and clinical quality improvement research seminars.  We also want to map to the needs assessment results that we did over the last several months.  There are also other venues for in-person training that we’re trying to organize, including workshops and courses at the V.A. HSR&D meeting, which happens in usually in February, the society for general internal medicine, AcademyHealth, a QUERI meeting and others.  And the ones that we have had to date have included -- our first one was from Dr. Missy McNeil at Pittsburgh V.A., the University of Pittsburgh and Sarah Scholle from the National Committee of Quality Assurance on V.A. patient-centered medical homes and patient center care for women veterans.  I'm pleased to say that was one of the highest attended sessions that I think the cyberseminar's history has had, of 672 people either on the call or downloaded the talks thereafter.  The second was led by Dr. Lori Bastian of the Durham V.A., on improving care for women veterans moving to interventions and implementation, reprising the role from the women's health services research conference from last July.  Dr. Bevanne Bean-Mayberry followed with a system, a summary of the systematic literature review, updating the one published in 2006, and you can see in each one of those, a remarkable participation of those of you in the field to learn more about this area.  Our last three are shown here, Dr. Donna Washington provided a summary of the findings of a national survey of women veterans with a discussion of the women veterans strategic healthcare group.  We were pleased to have Dr. Bob Wallace, the chair of the institute of medicine’s board of populations, which including a focus on the military and veterans, and he provided a book review on the institute of medicine’s report on women's health.  The most recent one before today's spotlight on women's health cyberseminar was by Dr. Susan Frayne, working in partnership with Dr. Patty Hayes, who is the chief consultant for the women's strategic healthcare group on the women’s health evaluation initiative, basically summarizing some substantial work they doing over a year or two, to create a source book based on secondary analyses of the V.A. data. 

Now, we did get to complete a needs assessment of the folks that have been involved in the women's health research interest group who are in the listserv and the top training needs that people described were, number one, not surprisingly, an implementation research, statistical methods for evaluating gender or sex differences, the influence of organizational factors on quality or the impact of health system redesign on care.  Intervention design, using the very rich administrative data resources that are available within the V.A. as well as sampling strategies.  They also talked about the areas they want to learn more about, which is going to provide us guidance for the kinds of things we provide to all of you in the coming months.  The top one was on quality of care for women's veterans, understanding how to measure it and what the variations are and to help people prioritize it.  Access to care.  Women veterans mental health, primary care, post deployment health, intimate partner violence, and military sexual trauma.  We also asked them about barriers to conducting V.A. women's health research.  Many still described having difficulty obtaining funding, insufficient protected time for research and that applies specifically to our clinical scientists and researchers who have to get funding to allow them time to focus on research and to identify other people who can take the clinical time from them.  Difficulty accessing female research subjects which, we hope to remedy with the practice-based research network, insufficient access to statistical programmers, to make use of the V.A. data and to work with trial results and the like.  Difficulty identifying potential collaborators and a lack of familiarity with national VA women’s health policy issues.  All of which the Consortium can help manage.  We're also developing a mentorship program which requires outreach and recruitment of the mentors themselves.  I think we have identified at least 12 to 15 MD and PhD investigators that represent a diverse set of topical areas that are willing to mentor others.  We're working to identify a process for identifying mentees that will be good matches, and identifying good matches for them along the mentors and identifying sources of support for mentees.  So we have the benefit of the V.A. women’s health fellowship program, the V.A. HSR&D career development award program, there is a V.A. MIAH research fellowship that may not provide covered time for salary but may provide travel and specific training in this area and the like.  And there are the NIH Birch and other type of awards and the Robert Wood Johnson Foundation clinical scholars and general faculty scholarship awards.  We'll probably put together a cyberseminar describing some of these in detail for people who are eligible and interested in moving forward to get that kind of career development support. 

In terms of technical consultation, I have to say that much of this work so far and has been through e-mail consults and troubleshooting.  I get a frightful amount of e-mail that I distribute to others and try to triage the kinds of needs that people have, which I suspect will increase as we go forward, but I think what we're hoping to do is build the communities of practice and key topical areas based on the top priorities that people noted in the needs assessment and try to launch regular conference calls with moderators or facilitators in the form of senior investigators with expertise in these.  So that we begin to brainstorm together and to help identify ways to get people funded in this area and move forward in that matter as we help each other.  We continue to move on in small group and one-on-one consultation, setting up telephone calls and meeting at people's sites where we happen to be there for other purposes, to focus on research development and to provide a certain degree of scientific review preparatory to proposal submissions.  Those of you who have already submitted proposals know that we're looking at a couple of tight funding years the next two years and any kind of advance review, you know, is a good idea at this juncture, to increase the chances of folks getting funded.  And some of the technical consultation areas people were asking about were in study design and including how to achieve adequate numbers for women veterans, survey design and developments and IRB issues.  These are the kinds of areas we can provide substantial consultation and support in.  The large database analyses and cost analyses, the Palo Alto group has Dr. Ciaran Phibbs, who is part of the health economic resource center or HERC at Palo Alto, who is involved in this initiative.  We have Dr. Allison Hamilton, a qualitative methods expert and in focus groups and semi structured interviews and in-depth observations and analysis.  We have Dr. Martin Lee in addition to experts at the cooperative studies program coordinating center, in statistical analysis and calculations and as I have mentioned, Dr. Brian Mittman and many of us who do implementation science and research. 

There were additional resources or services that people requested  in the needs assessment and that included putting together a newsletter of conferences and funding opportunities, keeping people abreast of V.A. policy initiatives and research events so we can develop that and make that available.  Ongoing consultation and technical assistance, developing competitive women's research grant proposals, ongoing support for multisite research and we will have a session that will be sponsored by PRIDE, the group in V.A.'s office of research and development who work on and who have led the design and development and oversight of the central IRB process, for example.  They want to help in developing relationships with clinicians and leaders for multisite research.  This is particularly important for implementation science because we don't have any control over what is going on in the practices and I refer to it as illusion of control as researchers and the relationships that you have with the clinicians and leaders become important to have this implementation science and to help people identify collaborators.  We're active in doing that now. 

I alluded to earlier the VA Women's Health Services Research Field-based Meeting that we held in July 2010, one of seven field-based meetings that the health services research and development service funded last year, we were very excited by having the opportunity to have this kind of meeting.  Virtually every office in the V.A. central office and every major group there participated and had a representative,  if not several representatives, including representatives from the Department of Defense, Department of Health and Human Services, including NIH, Office of Research on Women's Health, the NIMH Bureau of Women's Health and the Agency for Healthcare Research and Quality.  We have representatives from the Department of Labor, the Institute of Medicine, the National Committee for Quality Assurance, the Society for Women's Health Research, RAND, and representatives from the Senate and House Veterans Affairs Committees and selected representatives from Veteran’s Service Organizations.  In addition to that, we had over 100 health services researchers from across the country that presented over 75 oral and poster presentations.  I am pleased to say that people appreciated the opportunity for the networking.  There was a great mix of V.A. and non-V.A. participants.  There was direct health with professional development and a lot of side bars with people that created relationships that have continued and we provided a lot of information on broad health services research knowledge, and you can see the other kinds of activities we supported at that day and a half long meeting.  That kind of opportunity developed ideas for new women’s health research.  There was a lot of people rated highly, the positive impact on their likelihood of pursuing this as a field.  We helped identify a bunch of new mentors for people and connected them up at the meeting, and overall, people thought the conference was worthwhile and wanted ongoing updates about what was going on with this kind of research.  The majority also felt that the balance of topics was right.  If anything, they wanted more.  They wanted to learn about the leadership needs and priorities, they wanted to learn about implementation again, time spent on networking and fostering collaboration and actually, if anything, they wanted to top it, the conference to last longer and we were very gratified by that.  What was important is at the end, they said 96% of the people who came to that meeting thought it was a very important thing to have a repeat and thought it should happen every one to two years and there is interest on the part of HSR&D Service currently to consider doing that meeting every two years.  But as many of you know, it all depends on the budget and how things move forward.  I think at a minimum, we know that there is substantial interest in the field moving forward, and we hope to continue to build on the excitement that we have helped generate and that has come from the dynamic nature of those of you doing work in this important field.  

Finally, we continue to do work in dissemination beyond conferences and these other activities I’ve talked about.  There was a call for papers which that came out at the same time as the conference last year for a special issue of the Journal, Women’s Health issue.  And they have been supportive of women veterans research and by being one of the journals to publish more articles and on V.A. topics compared to many other journals.  A final set of manuscripts is now under revision and review and we hope that  the plan is for this to come out in July or August.  The articles will not only be available for those who subscribed to women’s health issues but available in PDF broadly.  We're developing technical reports on methods and procedures that will be available on the website in the future and develop more content for the existing office of research and development website and the intranet within V.A. Sharepoint websites and we talked about whether to have a social networking site, some Facebook kind of version that the V.A. will allow, that will allow us to have more informal conversations in the meanwhile.  And finally, we have a call for papers that will be coming out sometime in late 2012, for another supplement focus on military women and women veterans in the journal of internal medicine.  With that, I am going to stop and thank you for your attention and patience with that much content and detail and see if there are any questions. 

>> Thank you so much, Dr. Yano, for that comprehensive presentation and while we get to the questions and comments, I want to remind folks if you want to submit a question or comment at this time, open up your Q&A in the upper left-hand corner of the screen, click on the Q&A tab and type your question or comment into the top box and press Ask.  While we're doing the Q&A, I would like to you take note of the evaluation forms that have come up on your screen.  Please take a moment or two to provide us feedback.  This is an iterative process.  We're taking your comments and questions into consideration.  At this time, I would move to the first question, which is: Will this presentation be available to us for later viewing? I'm happy to take that one. 

>> Go ahead.  Your area. 

>> You can download a PDF version of the presentation at this time by going to the upper right-hand corner of the screen, click on the handouts icon, looks like three pieces of paper stacked on top of one another.  And we recorded the session and we'll be posting the archive video on the internet, along with the slides and audios within the next day or two.  You can access it by going to the HSR&D web page and click on the cyberseminar catalog.  Our first question aside from that is: when did you say the issue of focusing on women veteran health in JGIM will be coming?

>> The call for papers will be developed some time next year and we're still identifying the guest editors for that and I think Dr. Lori Bastian agreed to be one of the guest editors for the Consortium at the Durham V.A.  So once we get the call for papers out, we'll send it out very broadly and that will go to the university partners as well, probably through academy health and through the society of general and internal medicine and traditional V.A. sites.  So, we're hoping to have the actual issue be out sometime in mid-2013 and that is early for us. 

>> Thank you for that answer.  The next question is: how do we get access to the listserv?  And I'm happy to add people.  I just need their e-mail address. 

>> Yes.  If people can go ahead and send your information to either Dr. Ruth Klap or myself and we'll get you the information on the listerv if Molly doesn't send it out directly. 

>> Thank you.  The next question is: You mentioned military women along with women veterans.  I assume you mean active military women personnel.  Is the goal with D.O.D. research personally, also is the availability to do D.O.D. data sources going to be quote, unquote, easier for researchers to get it better? 

>> Okay, we definitely are hoping for improved cross-collaboration with the D.O.D. research personnel and one of the cyberseminars that we are organizing has -- represents a workshop delivered at the Women’s Health Services Research Conference, including several of the D.O.D. colleagues.  So that question, we'll bump that up in our priority and movement to making that happen.  Whether or not the availability of D.O.D. data sources is going to be easier, that is a good question and that is something we're working on and people are working at levels way beyond our own, so I will make sure that when that V.A.-D.O.D. collaboration cyberseminar is put on, we get someone to address that question specifically. 

>> Thank you. The next question is: what is the chance of people who are not currently involved in research getting involved in at this point in time? 

>> I would say there are lots of different opportunities for getting involved, depending upon the person's interests, energy, time, you know what, your training and background is.  There are lots of different levels of participation in research, and I'm pleased to say most of the people who are senior investigators to the area are bringing along people who have less experience so they can get established.  I would say it would depend upon the kind of area you're interested in and whether or not there is active research going in that area or if we think it's a high enough priority to get funded through HSR&D or other mechanisms at this time.  You won't know without asking.  If there is interest, e-mail us and we'll give you more specific information based on your specific interest. 

>> Thank you for that information.  The next question is: is the paper by Mayberry Bean in JGIM 2010 January, the title is integration of women veterans into VA quality and improvement efforts. 

>> I’ll have to double check which that is.  The integration of women's veterans and V.A. quality improvement research efforts is a paper I'm actually first author on and Dr. Mayberry is part of that.  I'll have to double check what the 2010 reference was.  It's probably to her systematic review completed in 2010, which is a report that is available.  E-mail us the review or show you where the web link is to have access to it. 

>> Thank you for that answer.  The next question: Can you go through a quick timeline of how you first got started with developing this network and what tools, processes you use to keep track of the researchers? 

>> That is a good question.  I have been trying to get V.A. women's health research moving probably since I came in the V.A. in 1989.  Chiefly from the perspective of, we had a big study to evaluate primary care development and we had specific resources and really thought that we were going have a difficulty including enough women and so we kind of did it anyway and continue to connect with other people over time, connected with the woman's veteran health program, which it used to be called.  Identifying what their needs were and continue to provide data sharing opportunities, collaborative opportunities, always just kept the door open.  We have been working on it for some time.  The consortium in terms of where it stands right now, has accelerated dramatically the last two to three years and part of it is these opportunities, as mentioned the, having the JGIM special issue in 2006, told people there were enough researchers and enough interest in this area that maybe if they were interested in it before, there could be a opportunity for them to participate.  In terms of keeping track of it, I have to take my hat off to our women's healthcare research program managers, the scientific portfolio or program manager Linda Lipson at V.A. HSR&D service.  One of the smartest things they did was to hire someone to track the portfolio and she does that.  And for us in the consortium, it's Dr. Ruth Klap, the Women's Health Research Woman's Program Manager who keeps tracks of what people needs are and I hope that answers your question. 

>> Thank you for that. And we do now have the reference link to the Mayberry-Bean article.  It is http://www.ncbi.nlm.nih.gov/books/NBK49179 .  The next question is: has there been much research on women veterans and -- veterans and advanced directive completion? 

>> That is a good question.  I'm not familiar with at least an HSR&D funded study on that.  I think that we do not have that many active projects on issues for either terminally ill or older women veterans, and I think it a gap that should be filled. 

>> Okay.  Thank you for that answer.  The next question is: interested in conducting women's health research at Hampton.  Is there any research being conducted that needs to be replicated or in need of additional sites for their study? 

>>Another very good question.  I would recommend that you get in touch with Dr. Klap so that your interest in having Hampton get involved in research can be registered along with other sites.  And we're ready to expand the research network that that might be something that folks at Hampton would be interested in having done.  Happy to look into that further. 

>> Thank you for that answer.  The next question: How should academic researchers not currently affiliated with V.A., who have experience with interventional research methods connect with research?  I work with D.O.D but I want to work with V.A. 

>> Again, please e-mail me.  This -- there is so much rich information that we can share with each other where we can help connect with you people based on the kind of research that each one of you is interested in.  We, we, I think that the opportunity -- we have a lot of university partnerships, not only are all of us university professors in the V.A., but we have opportunities to create collaborations that take advantage of the expertise wherever that may be and we are very sensitive and the V.A.'s sensitive to not developing grants that are pass-throughs and basically there is the V.A. P.I. and the money goes to the university.  We're not allowed to do that, these are intramural research base dollars and other folks are getting funding from V.A. and arc other and locations where there are so many opportunities and ways for figuring out how to move research forward and please go ahead and e-mail us.  We'll so if we can connect you to other folks. 

>> And actually one of the, one of our questions that just came in is: what is the e-mail address, please, to connect with the speaker. Would you like to -- . 

>> Elizabeth.yano@va.gov.  It's at the end of the slides if you need it.  If you didn't get to those, it's Elizabeth.yano@va.gov.  Or Ruth Klap, Ruth.Klap@va.gov.   

>> I'll put up that final slide at the end of the session.  It will be on the screen at the top of the hour.  And the next question is: are there any projects being conducted by nurses in the V.A.? 

>> Yes, yes, in fact -- in fact, within HSR&D services, that is one of our services.  Within HSR&D service, there is a nursing research initiative and you have to be a nurse in order to principle investigate the P.I. on those grants and if you e-mail us, we'll get you the linkage to the nursing research initiative and there are many nurses, many who are Ph.D conditioned RN’s and many nurses who conduct other research trials and studies outside of the research initiative as well. 

>> Thank you for that answer.  The next question is: is there any research being conducted to look at intimate partner violence among returning female veterans? 

>> There is and if you e-mail us, we can connect you to both the HSR&D website that describes, and that is a key thing.  To make sure that on the HSR&D website, you can search on any topic area and get abstracts and the name of the principle investigators for all the funded studies and we're aware of folks developing work in this area so, yes there is and happy to connect to you those folks. 

>> Excellent, thank you for that answer and, once again, would you like to tell people how they can join the Women's Health Consortium listserv? 

>> Yes, I don't know -- there is a web link they have to have.  We can send it out to all the folks that registered, if that would be help will. 

>> Absolutely, I'll be happy to send it out with the archive e-mail and all of our attendees will receive it the next day or two and they can follow the direct link. 

>> Also, if folks are interested in being a member of the V.A. Women's Health Research Consortium, we'll send out a membership form to help us identify what folks interests are to hook them up to resources and that is coming out shortly for anyone interested in being a member. 

>> Great, there is another question.  Are there any research opportunities for physical therapists in the area of pelvic floor dysfunction in women?  I'm a clinician who is interested in further research in this area. 

>> Actually there are and I don't know about the currently funded studies but in the rehabilitation R&D service, on the study of women vet reasons specifically.  If you e-mail us, we can connect with you Linda Lipson and who can connect to you the rehabilitation folks in that area. 

>> Thank you for that answer.  We have, I think, reached the end of our questions and we do still have a few minutes remaining if any of our attendees would like to type in anymore questions or comments for Dr. Yano, if you would like to give concluding remarks. 

>> I thank everyone for their participation today.  We're excited about the kinds of differences we can make with research in terms of practice and policy, and we're incredibly fortunate to have people with the vision and also, frankly, the appreciation of research and what it can do for improving practice and policy in the form of Dr. Patricia Hayes, who is head of women's veteran health strategic healthcare group.  Having these kinds of people in Washington who understand the kinds of benefits research can have really moves us forward in ways that make research more exciting than it was to begin with and people are hungry for learning about the evidence and understanding how it can help improve care, how it can help improve access and so I just encourage you to consider these resources available and to see if we can help get you started, you know and go from there.  Sometimes a lot of work to do research, but it's incredibly gratifying.  And I really thank you for your attention. 

>> Excellent. And we are already receiving positive feedback.  People are writing in saying this was a wonderful session, thank you very much.  So, I want to take this moment to plug the next Spotlight on Women's Health cyberseminar, which is presented by Dr. Paula Schnurr, on Methodological Issues in Psychotherapy (and other Nonpharmacological) Treatment Research and that is taking place April 7th at 12:00 p.m. eastern time.  To register for that seminar, you can go to the HSR&D website and click on the catalog and register at that site and at this time, I would also like to put up the last slide so your information is on there and -- 

>> Great, thank you so much. 

>> Absolutely.  Thank you for a wonderful presentation and we do have about four minutes left until the top of the hour.  If we have covered everything -- here comes another question as I say that.  Another respondent is excited to hear about the research being done with women veteran's and do hope that nurses will be encouraged to get involved with some of the research.  We have enjoyed this session.  Thank you for that positive feedback and also, I hope you were able to fill out the evaluation form.   Thank you.  And thank you, Dr. Yano.  I think we have reached the end of the presentation and I -- I hope everyone will join us on the 7th for Dr. Schnurr's presentation. 

>> Thank you so much. 

>> Thank you.  This formally concludes today's HSR&D cyberseminar.