Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series
Center for the Study of

Healthcare Provider Behavior

I t ti n egration of Women V t e era

into VA Research:

What Researchers Need to Kn

Elizabeth Elizabeth Yano, PhD, MSPH (VA Greate

Greate

Susan Frayne, MD, MPH (VA Palo Al

Co‐Directors, VA W ’ omen s H lh ea t R h esearch 
Integration of Women Veteran

VA Research: Overview of Toda

• Part 1: Why it is important important to integrat

integrat

women veterans into your VA researc

• Part 2: Submitting grants pp g ro osing t

VA Women’s Health PBRN
Center for the Study of

Healthcare Provider Behavior

Enhancing the Value of VA Re

Why Integrate Women Veterans in

VA R h esearch Pjt ro ec s & Plan

Elizabeth M. Yano, PhD, MSPH

Director, VA Women’s Health Research Consortium

Center for the Study of Healthcare Provider Behavior, VA Great

Professor of Health Services, UCLA School of Public He

Women’s Health Cyberseminar Series

October 4, 2011
What is the Problem? Problem?

• Research Research participants participants should represent represent t

population(s) for whom resulting treatm

care improvements improvements will be implemented implemented

– Women historically under‐represented in re

• Concerns Concerns about harm of potential potential exposures exposures on 

fetuses

• Women of childbearing age excluded from resea

– Knowledge of treatment, intervention, care 

effectiveness among women extremely limi

• E l ar y 1990s Æ fd l e era agencies reversed th i e r p

• Slow gains in knowledge, some large women‐foc

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
What is the Problem? Problem?

• Federal Federal agencies agencies now require require inclusion inclusion ena

ena

analyses of sex differences in intervention e

• Cost cannot be used as a justification justification for their e

e

• Effective outreach programs to recruit women 

now required

– Research within VA has similar requirement

include include women veterans veterans as subjects subjects as app

app

– Historically, many researchers have indic

• Will include women proportionate to VA rep

• Will not include women due to numerical m

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
What is the Problem? Problem?

• Rapid growth of women in military military an

– “Proportionate” now means you need 10

in your study

• Has to be sufficient #s to support subgroup • Should be capable of publishing sex differen

WV data in their own right

– Reviewers less likely to accept their exclu

part because HSR&D has invested in infr

to facilitate their inclusion (PBRN)

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
What is the Problem? Problem?

• General General sampling sampling strategies strategies may be

insufficient to recruit adequate WV sa

– Women veterans have different age distr– Women veterans have unique health car

(e.g., gender‐specific, higher MH burden

– Women veterans veterans have different different patterns patterns 

(e.g., more reliance on fee basis/contrac

– Women veterans veterans may be seen in differen

differen

(e.g., some use women’s clinics for prima

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
What are some Solution

Solution

• Better understand

– Women veterans as a p po ulation– How women’s health care is organized in – How quality quality of care compares compares between between m

women veterans

– The policy and practice context for VA w

health care

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
# of Women Veterans Using V

Doubled over Past Decade

Cohort: Women and men Veteran VHA users in year. Women in FY09: N=292,921; Men in FY09: N=4,846,869.

Source: WHEI analysis of ADUSH Monthly Enrollment Files, FY00–FY09.

.Sourcebook: Women Veterans in the Veterans Health Administration - Volume 1 (December 2010)
Women Veterans

• 10% of veteran population by 2018• Younger, on avg, than male veterans (48 

• Less likely to use VA (15% vs. 22% in 200

– But VA enrollment now >2x national level (>

– Barriers to VA care: lack of information abo

eligibility eligibility, benefits benefits, and available available WH servic

servic

perceptions of poor VA quality

– But among users, WVs more likely than non

low income, w/o insurance, poor health and 

support and service‐connected disability

• Top dxs: PTSD, h i ypertension, d i epression

hyperlipidemia, chronic low back pain...

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
How is VA Women’s Health C

Organized?

• Challenge of organizing gender‐specif

gender‐sensitive services in system hifocused on treating men

• Numbers Numbers of women veterans veterans in any o

varies considerably

– Affects how care is organized at each VA

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Changes Changes in VA WH Care Arrange

Arrange

Women's PC

Clinics

Designated

44% gen

G C

WH Providers 

p<.005

g 

exam

General PC

w/o Desig WH

p<.05

0% 20% 40% 60% 80% 

Percent of VA Facilities with each PC Delivery 

 A

Source: Yano, Bean-Mayberry, Washington. Impact of practice structure

on quality of care for women veterans: Phase 2. Final Report, 2010.
Changes in WH Service Avail

Cervical CA

Screening

Screening

Mammograms

Contraceptive

Services

Non-Surg Breast

CA Tx

Breast CA

Surgery

0% 20% 40% 60% 

Percent of VA Facilities with each PC Delivery 

 A

Source: Yano, Bean-Mayberry, Washington. Impact of practice structure

on quality of care for women veterans: Phase 2. Final Report, 2010.
VA Women s Women’s Health Car

• Care for women veterans veterans can pose consi

consi

training/experiential requirements for w

with limited limited exposure exposure to female pts

– Gender‐specific care (e.g., reproductive hea– Care for conditions conditions of higher prevalence prevalence am

(e.g., osteoporosis)

– Different clinical clinical presentations presentations (e.g., MI)

• Difficulty with provider/staff gender sen• Privacy problems problems, procedural procedural barriers barriers

• Safe, comfortable care environments

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Gender Disparities Disparities in VA Quality Quality 

• VA quality among women outperforms m

measures among commercial, Medicare 

M di id Medicaid groups, b t u ...

• Significant, durable gaps in care existing 

within VA

– CRC screening, immunizations, depression s– CVD risk (lower use cholesterol meds, poore

control)

– Diabetic care (lower rates of proteinuria tes

exams, poorer LDL control)

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
VA Women s Women’s Health Leader

Leader

• Overseen by Women Veterans Health 

Healthcare Group (Office of Patient Care 

– Provides strategic direction and program

support support to address address WV health care need

– VACO level senior staff leading comprehe

care, reproductive reproductive health, medical medical educa

educa

– Regional Deputy Field Directors and loca

V t e eran Program Managers

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Challenges and Potential Potential Sol

Sol

• Und d erstand context of how care is d li 

e ve

– National data available on local care variatio

may f ilit t facilitate st du y d i / li design/sampling ch i o ce

– Consider whether interventions need adapt

• Work with VAs that have established WH

programs to facilitate WV inclusion

– Local community building, networks, trust

– Research‐clinical partnership opportunities

– Advantages may be offset due to high casel

limited clinical backup or admin support)

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Challenges and Potential Potential Sol

Sol

• Women veterans’ younger age may co

research p p articipation

– Work and/or childcare obligations– Few VA facilities facilities can accommodate accommodate child

child

– But lack of accommodation may bias sam– Adequate cash incentives may offset chi

arrangements during participation

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Challenges and Potential Solut

Implementation Studies

• Step #1: Appraise the samples from w

evidence base was drawn ( , i.e. eviden

effectiveness by gender)

• Step #2: Examine Examine the distribution distribution of p

p

and patterns of care in target practice

– How does the evidence relate to the pla

implementation environment?

• Step #3: Determine need for adaptatio

Source: Yano EM et al. Integration of women veterans into VAquality improvement research efforts. JGIM 25(Suppl 1):56-51, 2010.
Major Infrastructure Solution to In

Women Veterans in VA Resear

Women’s Health 

Research

Women Veterans’ 

Practice Based

Consortium

Practice Based

Research Network

So how dKeep listen

So how do I use it?Email requests toruth.klap@va.gov for triaging for triaging

VA Women VA Women s’ Health

Practice-Based Research Net

Submitting Grants Prop g osin to Use t

Susan Frayne MD, MPH

Director, Women’s Health PBRN

Center for Health Care Evaluation, VA Palo Alto Health C

Associate Professor of Medicine, Stanford Univer

Women’s Health Cyberseminar Series

October 4, 2011
Poll

• Do you provide clinical care to women

Veterans?

• *Yes

• *No
Poll

• Do you conduct research which focus

women Veterans?

• *Yes

• *No
Poll

• Do you conduct research which includ

women Veterans?

• *Yes

• *No
Poll

• Are you considering submitting a gran

p p ro oses to use the PBRN?

• *Yes

• *No
OUTLINE

• Design of the PBRN• How to apply to use the PBRN in a new • Why to use the PBRN

• Audience questions
Women’s Health PBRN: D

• Network of partnered VA facilities• Provides infrastructure

– researcher‐initiated, funded research – clinician‐initiated quality improvement 

• Implementation Evaluation Projects

– For early test of infrastructure
PBRN Philosophy:

Bi‐Directional Collaboratio

Practice‐based research questio

CLINICIANS RESEA

Di i ti Dissemination of research fi di n 
***How to Apply to Use the PB

• Contact the PBRN Coordinating Center (CC) [include b

– Susan Frayne MD, MPH (susan.frayne@va.gov)– Diane Carney MA (di @ ane.carney@va.gov)

• For exploratory discussion, you will be asked to em

a brief description of study, and your CV

• Exploratory discussion will include topic, potential 

needed from CC, and proposed level of involvemesite research staff and clinical staff

• Investigator will complete a form summarizing stud

• CC will approach sites regarding potential participa

• Investigator will have ongoing discussions with CC 

leads as proposal development proceeds, to work 

such as specifics of site roles, budget, etc.

• For studies that the PBRN accepts, the PBRN Direc

write a letter of support, to accompany the grant p

submission
Why should I submit a

grant using the PBRN?

Five Good Reasons....
Why should I submit a

grant using the PBRN?

Reason #5:VA requires inclusion of women, but are a relatively relatively limited limited number of wo

at any one VA facility.
Limited Number of Women Veterans at a Sing

Source: Fra

yne et al 2011, Women’s Health Evaluation Initiative 

(W
Why should I submit a

grant using the PBRN?

Reason #5:VA requires inclusion of women, but are a relatively relatively limited limited number of wo

at any one VA facility.

Investigators can use the PBRN tosupplement supplement the number of women 

their studies, even if the focus is no

women.
Why should I submit a

grant using the PBRN?

Reason #4:Women Veterans have unique

characteristics that need to be taken 

account when including them in rese
Special issues arising in research focu

women Veterans

– Clinical issues

• Pregnancy

• Menstrual cycle

• Parenting

• Trauma exposure/trust• Distinct patterns of illness• Distinct Distinct patterns patterns of health care utilization utilization

– Health care delivery issues

• Variability in systems of care for women’s p 

rima

mental health care

• Local leaders in women’s health (e.g., Women V

Program Manag , er Women’s Health clinical direcCoordinator, etc.)

– State of the evidence base

• For some topics, relati el v y limited limited women’s hea

base to inform intervention and implementation 
Why should I submit a

grant using the PBRN?

Reason #4:Women Veterans have uniquech t i ti haracteristics th t a need to be t ka en 

account when including them in rese

PBRN team, combined with Consortnetwork network, have expertise expertise in content content 

and methodological issues arising in 

study of women Veterans.
Why should I submit a

grant using the PBRN?

Reason #3:Identifying sites can be a challenge.
Why should I submit a

grant using the PBRN?

Reason #3:Identifying sites can be a challenge.The PBRN has a growing network ofexisting sites:*Site lead has been identified*Characteristics of the site and its pare known
Why should I submit a

grant using the PBRN?

Reason #2:R i unn ng a multi‐site st du y is a ch ll a e
Why should I submit a

grant using the PBRN?

Reason #2:R i unn ng a multi‐site st du y is a ch ll a e

The PBRN provides research infrastr

to help with administrative and logiaspects aspects of running running a multi‐site stud
Some Services Services Provided Provided by PBR

• Addressing local clinical clinical logistics logistics issues

– Clinician engagement in recruitment; space 

specifics of local clinic operations; etc.

• Addressing local research administration 

issues

– Local R&D procedures; HR issues; unions; et

• Navigating regulatory requirements

– Central IRB; between‐site data transmission

• Conducting multi‐site data collection

– Assuring standardized, cross‐site Interviewe

quality control in transmitting raw data to c

repository repository (e g. ., through through CSP systems); systems); etc.
Why should I submit a

grant using the PBRN?

Reason #1:Some women s women’s health researchers researchers in 

lack local collaborators.
Why should I submit a

grant using the PBRN?

Reason #1:

Some women’s health researchers researchers i

lack local collaborators.

The PBRN has an enthusiastic, collastaff, ready to help!
Our L d hi ea ership Team

• Coordinating Center (Palo Alto)

Susan Frayne, MD, MPH, Director(susan.frayne@va.gov)Diane Carney, MA, Program Manager (diane.carney@va.gov)Ciaran Phibbs, PhD, Co‐Investigator (HERC)

Julia Lin, PhD, Statistician (CSPCC)

• Clinical Trials Division Division (Durham) (Durham)

Lori Bastian MD, MPH, Division Director

• Health Care Delivery Delivery Division Division (Greater (Greater Los Ang

Ang

Bevanne Bean‐Mayberry, MD, MHS, Division DirectorElizabeth Yano, PhD, Director, Women’s Health Research Ruth Klap, PhD, Program Manager, Women’s Health Rese

• Post‐Deployment Health Division (Iowa City)

Anne Sadler, PhD, RN, Division Director

Resources

• HSR&D W ’ omen s H lth ea R h esearch

– Includes searchable women’s health literature data

searchable women’s health research portfolio

http://www.hsrd.research.va.gov/for_researchers/womens_health/

• Women s’ Health Evidence Evidence Synthesis Synthesis Reports Reports

http://www.hsrd.research.va.gov/publications/esp/women.cfmhttp://www.hsrd.research.va.gov/publications/esp/women‐vets.cfm

• Women’s Health Issues supplement

http://www.whijournal.com/content/supplements

• Cyberseminar series

http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/catalog‐

archive cfm?SeriesSortParam=y&SeriesIDz=56##Archived archive.cfm?SeriesSortParam=y&SeriesIDz=56##Archived
Contact Information PBRN

Susan Frayne MD, MPH (susan.frayne@

Diane Carney MA (diane.carney@va

Contact Information Consortiu

Elizabeth Yano PhD (elizabeth.yano@v

Ruth Klap PhD (ruth.klap@va.go

ruth.klap@va.go

Please contact us—we want to hear from