**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**Women’s Health CREATE**

**Presenter: Elizabeth M. Yano, PhD, MSPH**

**January 27, 2014**

*Dr. Yano:*Thank you all for joining us on this overview of the Women’s Health CREATE one of ten funded by VA HSR&D Service.  As many of you may know and some of you may not know women veterans are among the fastest growing segment of new VA healthcare users system wide.  It’s really been legislative changes that opened military careers to women.  For example, 20 percent of new recruits are now women.  The legislative changes also mandated VA to deliver gender-specific care.

There has also been increasing efforts to enroll returning veterans from Iraq and Afghanistan also called OEF/OIF and now also OND or Operation New Dawn into VA care.  What used to be an 11 percent market penetration is now well over 50 percent of those women Veterans enrolled in care.  Women Veteran VA users have also doubled over in the past ten years and are projected to be ten percent or higher of the total VA user population by as early as 2018.

There’s also been a rapid increase as a result in the numbers of women in childbearing years coming to see VA providers.  Forty-two percent of women Veterans for example versus 12 percent of male Veterans are under 45 years of age.  The complexity of their care demands are changing rapidly.

There’s also been evidence of significant comorbid physical and mental health conditions among women Veteran VA users.  They have a higher disease burden than female non-Veterans.  A comparable disease burden to male Veterans even though on average they are younger.  A greater mental health burden compared to male Veterans among VA users.  There are also high rates of sexual harassment, abuse and assault histories that have been demonstrated in the literature in terms of women Veterans experiences in the military.  With higher rates among those who use the VA.

Their numerical minority also creates real challenges for the VA.  There’s a historical predominance of men in VA settings.  There have been demonstrated and documented gaps in safety and privacy for women historically through the government accounting office reports and limited gender-specific service availability also historically.  VA providers on average had little or no exposure to women. 

A lot of the work that’s gone on over the last now 15 or so years has been examining both the health and health conditions of women Veterans, but also looking at the determinance of the quality of care that they’re able to get within the VA healthcare system.  One of these studies in particular we did here at the VA Greater Los Angeles with my colleagues Donna Washington and Bevanne Bean-Mayberry in partnership with Women’s Health Services and really demonstrated the extent to which Woman’s VA health clinics were associated with significantly higher rates of breast and cervical cancer screening through Pap Smears and Mammograms.  

Higher patient ratings of access, continuity and coordination despite many of these clinics being open five half days or six maybe seven half days a week compared to general primary care clinics that were typically open more half day sessions a week.  Interestingly, there were no other changes in some of the gender-neutral measures like colorectal cancer screening and the like.

The short in a nutshell what we’ve found worked and the results are needless to say much more complicated than this.  What’s comprehensiveness?  The availability of women’s health expertise, the skill mix necessary to account for and deliver the range of services women needed and the availability of services onsite as opposed to going to another VA or going to a private sector community provider.  We’re on average related to higher quality for women Veterans specifically.

One of the issues that followed was that the Under Secretary for Health passed a work group and established acceptable women’s clinic models.  This was directly with Women’s Health Services who then in turn developed a new VHA Handbook and a field-based set of assessment tools.  The Handbook is the Health Care Services for Women Veterans 1330.01 which came out in 2010.  The Women’s Assessment Tool for Comprehensive Health or the WATCH tool that helps sites really self-assess how they're doing in terms of comprehensive care delivery for women Veterans.

The key focal points in the Handbook of particular interest to us on the CREATE is that each VA facility must ensure that eligible women Veterans have access to comprehensive medical care, including care for gender-specific and mental health conditions comparable to care provided for male Veterans.  All enrolled women Veterans need to receive comprehensive primary care from a designated Women’s Health primary care provider who is interested and proficient in the delivery of comprehensive primary care to women irrespective of where they are seen and regardless of the number of women Veterans utilizing a particular facility.

This is particularly important when you learn more about some of our CREATE studies because in the past it was if you were in the community-based outpatient clinic and you had to travel 200 miles to get to the nearest Women’s Health Provider so be it.  That’s no longer an acceptable alternative.  The other key focal point is that the environments of care need to be sensitive to women Veteran’s needs, safety and dignity.

What is a CREATE?  It stands for Collaborative Research to Enhance and Advance Transformation and Excellence.  All the CREATE’s are described on the VA website as you’ll see below.  They were designed to be a group of coordinate research projects conducted in a focused high-priority area in partnership with VA leaders.

The Women’s Health CREATE goal was to use research to accelerate implementation of comprehensive care for woman Veterans.  Our principal partner is Dr. Patricia Hayes who is the chief consultant for women’s health services.  We focus on fundamental issues in how VA delivers care to women Veterans in the context of national VHA policy.  To ensure access to comprehensive health services within an environment to preserve privacy, dignity and safety.

Our aims are to examine patient provider and organizational barriers and facilitators to implementation of comprehensive care.  To assess the determinance of these factors underlying delivery of comprehensive care and their implications for quality and women Veterans experiences of VA care.  To evaluate the effectiveness and impact of alternate models of delivering and achieving comprehensive care for women Veterans.

There are five component projects that will be discussed in just a moment.  I’m not going to go through the details of each one because each project will describe itself.  We work together very collaboratively.  It’s been a wonderful experience in our first year already.

Our overarching CREATE partners are in Veterans Health Administration.  We are funded by the Office of Research & Development’s Health Services Research & Development Service.  As I mentioned our primary partner is Women’s Health Services with Dr. Hayes and also Dr. Sally Haskell, who’s the Deputy Chief Consultant for Clinical Operations and the Director of Comprehensive Women’s Health.  As well as Mental Health Services directly with Dr. Susan McCutcheon and we have thematic work through all five of our CREATE projects that focus on women’s mental health as well. 

Then we also benefit from additional project-specific partners.  For example, the National Primary Care/PACT Office, Office of Specialty Care Services, VISN Leaders, National Radiology and benefit from a National Executive Steering Committee and we have just initiated a National Women Veterans Council.  With that I’m going to hand this off to Dr. Susan Frayne.

*Alison Hamilton:*Actually it’s Alison.  *[Laughter]*  We’re going to tag team for what we call P1.  This is Alison Hamilton, good morning everyone or good afternoon.  I’m going to start us off by talking about what we call P1 or Lost to Care:  Attrition of Women Veterans New to VHA.  Susan Frayne and I are both PI’s on this project.

As Becky’s already mentioned we are seeing a tremendous growth in women in VHA.  For example, among women Veterans using VHA outpatient care in fiscal year 2009, 14 percent of those women were new meaning that they had not used in the prior three years.  We see a lot of geographic variability in the distribution of new women Veterans across the United States.  In this map here you can see the number of new women Veteran patients by home facility with the sizes of the circles corresponding to the numbers of new women Veterans at the different VA facilities.

Our study is focused on attrition.  It’s important to just first define what we mean by attrition.  By attrition we mean someone who has entered the VA healthcare system and then in any given fiscal year, and then does not use VA outpatient care in the subsequent two years after that initial visit.  Some early analyses by members of our teams indicated that attrition is common in women who are just starting to use VA and new women Veterans using VA.  For example, in fiscal year 2006 about a third of women Veterans met that definition of attrition, which is of course of concern to VA.

Our goals in this study are threefold.  We want to assess whether and how patient experiences of VHA care contribute to attrition to recognize patient subgroups that at risk for attrition and to identify promising patient-centered remedies for this problem.  Our study design is a mixed method convergent parallel design which means that we’re using both quantitative and qualitative methods concurrently and prioritize equally.  We also will be mixing the results during our overall interpretation of study findings.

Our conceptual model which Susan will show you in a minute incorporates two theories.  One the Anderson Behavioral model of Health Service Use and two, Consumer Choice Theory and now I’m going to turn it over to Susan to talk about our specific aims.

*Susan Frayne:*  Thanks, Alison.  We have two quantitative aims that use existing data sources.  Aim 1, is to identify predictors of attrition among a fiscal year 2011 national cohort of new women veteran VHA patients, about 50,000 patients.  Aim 2, is to characterize patterns of attrition over a nine year period of time.  

We also have two qualitative aims under the leadership of Dr. Hamilton and her group.  That allows us to hear the voices of women Veterans themselves about the issue of attrition.  Aim 3, is to understand perspectives of attriters and non-attriters which will be done through telephone interviews with a national stratified sample of 125 women primary care patients who are new to the VA in fiscal year 2010.

Alison will be drawing upon both attriters and non- attriters and drawing on high attrition and low attrition facilities.  Then in Aim 4 we’re going to explore the plans for future VHA use among current VHA users.  We’ll find out about women’s intentions from focus groups with recent VA users at two facilities.  

As Alison said, our conceptual model draws upon the consumer choice theory which posits that there’s two forces that drive consumer decision.  The characteristics of the available options that the woman has and the characteristics of the individual and we link that with Anderson Model to identify the patient characteristics of need, enabling and reinforcing.

We’ll look at the extent to which patient characteristics of VA care including their experiences with working with designated woman’s health providers and other aspects of their woman specific and non-gender specific care predict attrition.  For the quantitative aims, Aims 1 and 2, are key variables.  Our cohort is going to be women Veterans who are new to the VA and will take advantage of our collaboration with Women’s Health Services which has allowed us to develop a national database of women VA users that we call WHEI-M which is the Women’s Health Evaluation Initiative-Master database.

Our dependent variable will be attrition looking at whether women have continued to use the VA in the second year and third year after her index visit.  Then we’ll look at predictor variables that are the receipt of Designated Women’s Health Provider Care as a predictor of attrition and patient experiences of care, contextual factors, that gets at the consumer choice theory aspect, and patient characteristics as well.  I’ll turn it back to Alison.

*Alison Hamilton:*Thank you, Susan.  For Aim 3 we have three main research questions.  Regarding patient experiences we want to know how their experiences influence their decisions whether to stay in VHA or not.  We’re going to look at that in a number of different ways.  In terms of the organizational characteristics we’re really interested in how contextual factors such as community health resources, organizational characteristics and patient factors influence again their decisions.  Finally, we’re really interested in those patients that are perspectives on what improvements could be made that would reduce attrition.  What are modifiable factors related to attrition that could be addressed in future work?

Finally, for our aim for focus groups we’re going to be conducting these in Los Angeles in Iowa City.  In those focus groups which come a little bit later in the project we want to explore women’s current experiences of healthcare and also really hone in on what their plans are.  Do they plan to return to the VA, and what types of services and policies would they like to see changed or developed to prevent attrition, also to promote outreach to women.  We’d also like them to prioritize factors that they think would prevent attrition to really get them thinking about what they desire the most.

We’re really excited in the project to have the voices of women Veterans helping to guide future work and policy in this area.  Now I’m going to turn it back over to Becky who’s, oops sorry.  Who is going to talk about what we call P2.  Thank you very much.

*Dr. Yano:*Thank you, Alison.  The second study is on Impact of Delivery of Comprehensive Women’s Health Care in the VA and really builds on probably almost 20 years of work we have done here on measuring VA primary care and women’s health practice organizational structure and processes linked to quality.  I am joined by Dr. Danielle Rose and Ann Chou as my co-PIs.

As we’ve mentioned delivering comprehensive care to women Veterans can be a challenge in VA.  There’s a rapid growth in VA use, yet no changes in onsite availability of services.  In fact, in one of our last studies it looked like there was actually a decline in onsite service availability.  There are also wide variations in how local VA facilities achieve comprehensiveness.  Some provide comprehensive services through a general primary care or a PACT clinic and Women’s Health Clinics.  Some integrate mental healthcare versus others refer to an outpatient mental health specialty which may or may not have providers who are either same gender or are used to seeing women.

There are different levels of in-house reproductive health and gynecology services.  It’s quite a different matter depending upon which VA a women Veteran enters.  VA has increased its policy guidance on comprehensive care as I mentioned before and increased substantially the training that’s provided to primary care providers across the country with well over a thousand providers trained.

There’s also been an increased emphasis thanks to the dynamic work of the leadership of women’s health services to increase quality by gender reporting which has had substantial impacts on reducing gender disparities and care.  Nonetheless implementation varies and local barriers of facilitators vary.

In this project we’ll assess determinants of variations in the delivery of actual comprehensive care to women Veterans.  Then we’ll study the impact of those varying levels of comprehensive care delivery on their quality and experiences with VA care using other VA data sources.

Comprehensive care includes everything from first contact care where you usually go whether that’s Women’s Health or primary care or a deployment health clinic.  There’s also subsequent care for any health problem at any given stage of a patient’s life cycle.  Then the range of services available and provided considering the population needs with a focus on problem-related care.

That’s primary care, subspecialty care, mental health and gender-specific care organized from VA entry through each veteran care journey.  That also requires a personal relationship with the provider and the coordination needed to achieve timely care per standards.

Our basic study design and sampling plan is to develop and administer key informant organizational surveys to all VA facilities serving 200 or more women Veterans which will be about 300 practices across the country.  Using a key informant approach again which is identifying the most knowledgeable local either senior women’s health clinician or senior primary care clinician and the like.  Then we’ll identify both the variations with that survey, but also then link those data to guideline concordant chronic disease and preventive screening quality indicators that the VA already uses to self-assess its quality and what it can deliver to Veterans.  Then also link it to VA care experiences data on access, continuity and coordination.

We’ll be looking at organization determinants such as practice characteristics, in terms of the structural features of both primary care and Women’s Health programs, coordination mechanisms, quality improvement resources and environmental management as well as the influence of the larger facilities.  Including its size, its academic affiliation, its complexity basically the context within which care is delivered.  We will also look at area determinants.  No two VA’s may be alike, but it’s the urban and rural issues, the census region, the area characteristics within which Veterans live and VA’s deliver services and then the healthcare area resources.

We’ll look at corporate data warehouse data to look at these quality indicators I mentioned and then work through additional data sources through the PACT Compass and Corporate Data Warehouse and the Survey of Healthcare Experiences for Patients, also called SHEP, for some of our outcome measures.  

In this case I transition to myself on a third study here.  What we also call as Project 3 or P3.  This is a major trial that is a third project within the CREATE portfolio.  It focuses on Implementation of VA Women’s Health Patient Aligned Care Teams or Women’s Health PACTS.  Then I’m joined by an august senior and seasoned implementation scientist and general internal medicine physician, Dr. Lisa Rubenstein as well.

In addition to the VA Handbook and the efforts that are underway to deliver more comprehensive services for women Veterans the VA is also very much in the middle of the fourth or fifth year of implanting a patient-centered medical home model.  Now outside the VA those have been found to be associated with improved quality, improved patient and provider and staff satisfaction.  While reducing costs and actually reducing at least racial/ethnic disparities in care.

The VA’s model, PACT, holds promise for reducing women Veteran’s gaps in care.  It’s comprised chiefly of teamlets that include a three to one staffing ratio between primary care providers, nurses and administrative support.  Within the context of a larger primary care team a pharmacists, social workers, dieticians, health coaches and integrated mental health.  Then links to a medical home “neighborhood” if you will outside, which is the specialists, hospitals and other services that all patients should have and may need access to depending upon their health conditions.

With the goal of increasing access, continuity, coordination, comprehensiveness all using team-based care that’s designed to be patient driven and patient centered.  The dilemma is that how VA should adapt PACT to meet the needs of women Veterans was not part of the original iniative so there were no specific accommodations for gender-specific care or gender sensitivity in the original guidance.

There’s also no specific guidance on the women’s health clinic-based programs with some emerging evidence of course trying to achieve the same PACT criterion and quality that you would have in a general primary care clinic.  The Women’s Health Clinic Models also vary in delivery of their level of comprehensiveness across the country.  The VA’s Handbook on comprehensive care delivery does still fill key policy gaps.  It aligns with PACT, requires comprehensive primary care one-stop visits and it provides the needed policy attention to gender-specific care and sensitivity in any kind of clinic setting primary care or Women’s Health based.  It specifies those ranges of acceptable care models and attributes.

What do we do?  We have national strategic priorities in hand.  We have evidence of medical home effectiveness and early evidence of the promise and value of PACT.  We have evidence of primary care features and general primary care women’s health clinics that contribute to quality.  We led through funding from Women’s Health Services a national expert panel consensus development process to achieve criteria for what accounts for gender sensitive comprehensive care features.  What we needed was an approach to tailoring PACT to the evidence and women Veterans’ needs.

This lead us to this to this particular study which is to assess the effectiveness of evidence-based quality improvement, which I’ll describe more in a moment, methods for developing a Women’s Health PACT model.  This is in the context of what we call a cluster randomized control trial.  We’ll be looking at our ability to use these EBQI methods to help local practices achieve PACT features, achieve comprehensive care and achieve it in the context of gender-sensitive care delivery.

We’ll then look at the impacts of receipt of Women’s Health PACT concordant care on women Veterans’ outcomes such as chronic disease care, prevention, health status, use and cost.  Then we’ll evaluate the processes of EBQI-supported Women’s Health PACT implementation.  That’ll help us understand influences of practice context as I alluded to in Project 2.  We’ll document the methods and the implementation processes locally and look at barriers and facilitators using both quantitative and qualitative methods.  Then we’ll develop implementation and evaluation tools to take what we learned from the intervention practices in this trial to adapt, implement, sustain and spread to other VA’s nationwide.

What is the intervention again?  Evidence-based QI is an implementation strategy for adapting or tailoring research evidence to move it into routine practice and policy.  We are not evaluating whether PACT works, although under Aim 2 we’ll explore whether Women’s Health PACT concordant care does indeed improve women Veterans outcomes.  We’re not evaluating whether it’s better to deliver primary care to women in general primary care or Women’s Health Clinics.  Our participating medical centers span all care model types.

This is a multi-level research-clinical partnership quality improvement approach.  We use top-down and bottom-up features to engage local organizational senior leaders and quality improvement teams.  We use the national strategic directives as guides.  We use regional expert panels to set innovation design priorities, and we use local interdisciplinary quality improvement team design and implement local activities in the context of prior evidence and change methods.

Researchers in this case since control of practices that are across the country is only in an illusory concept really serve as technical guides and experts.  We train everyone in quality improvement; we help them structure their quality improvement activities.  We provide formative feedback and practice facilitation to support what they do on the ground.  These kinds of methods have been shown to be the most sustainable since we are really providing new skills to the people on the ground.

As a cluster randomized trial we’re working within four VA Veterans Integrated Service Networks or VISNs.  We will be randomly or actually have randomly assigned two experimental VA medical centers to the intervention and one to control.  That’s to support appraisal of variations in how each place implements evidence-based quality improvement.  We’ll capitalize in the VA Women’s Health Practice-Based Research Network.

We’ll be doing both formative and summative evaluation at baseline 12 and 24 months follow-up.  As you can see we will be doing Women Veteran Surveys on the far left side.  We were working with RAND to do primary care and Women’s Health Provider Staff Surveys.  We’ll be conducing practice surveys, stakeholder interviews, teamlet effectiveness interviews which is with our colleagues at UCLA and then utilizing VA’s expansive administrative data, quality, costs and utilization.  With that I’m going to hand off to our colleagues on Project 4.

*Donna Washington:*Great, thank you.  This is Donna Washington.  I’m the PI and Kristina Cordasco is the co-PI of Women’s Health CREATE Project 4 which is Controlled Trial of Tele-Support and Education for Women’s Health Care in CBOCs.

Okay, so women Veterans are only a small proportion of VA healthcare users.  As a result the VA primary care workforce’s exposure to and expertise in managing women’s gender-related care is quite variable.  To ensure high-quality care, VA mandated that every VA facility should have designated women’s health providers, which you heard about earlier.  We’re referring to them as DWHPs on the subsequent slides.  The designated women’s health providers are providers who are knowledgeable, interested providers proficient in the delivery of women’s healthcare.

They also instituted intensive training opportunities specifically women’s health mini-residencies to support training of these providers.  Continuous education though with reinforcement of learning points is needed in order to produce and maintain long-term gains in knowledge.  In a VISN 22 operations iniative we launched the first VA Women’s Health SCAN-ECHO.  SCAN-ECHO being a series of primary care provider and specialist clinical tele-videoconferencing sessions and this is for the didactic education and discussion of patient cases.

We also launched Women’s Health electronic consults which are secure electronic communications between primary care providers and specialists with specialists reviewing charts to provide care recommendations.  In combination, we call Women’s Health SCAN-ECHO and Women’s Health Electronic Consults or e-consults designated Women’s Health provider support.  This research project so Women’s Health CREATE P4 will evaluate the effectiveness of DWHP Support.

We have four specific aims.  Aim number one is to evaluate the effect of DWHP Support on Women’s healthcare quality and efficiency.  Where quality is assessed by guideline adherence and efficiency is assessed by specialist referral patterns.  Aim number two is to explore the impact of DWHP Support in changing provider behavior and their self-rated women’s health knowledge, skills and self-efficacy.

Aim number three is to assess attitudes about designated women’s health provider support and its use, specialist time for its implementation and other features that could influence its effectiveness, its sustainability and spread.  Then finally Aim number four is to develop tools to measure quality of Women’s Health Care in VA.  This aim is to support aim number one which looks at quality of care.

Women’s Health create project four is a four year mixed methods study with the intervention being rolled out one healthcare system at a time in what is called a stepped wedge design.  Our quantitative methods include a chart review to measure the quality and efficiency of care, surveys of designated women’s health providers to measure the perceptions of the program elements, program events, and to assess their self-efficacy in delivering women’s healthcare.

Our qualitative methods are comprised of semi-structured interviews with designated women’s health providers and with specialists to assess their educational needs and attitudes and perceptions.  The sampling plan for P4 is depicted here.  The intervention is being rolled out one healthcare system at a time.  These interventions are aimed at the designated women’s health providers within those healthcare systems.

The goal is to influence the care of patients seen by the designated women’s health providers.  In this particular project we’re looking at care for selected conditions.  To emphasize the target of this intervention are the designated women’s health providers, but it’s looking at the care of those providers.

Our data sources and measures for the quality assessment tool development aim includes literature reviews and expert panel methods.  For the quality assessment aims our data sources include administrative data that we’re assessing using the Corporate Data Warehouse and chart reviews that we’re conducting using CAPRI and VistAWeb.  For the designated women’s health providers’ self-assessment and for the assessment of their attitudes and perceptions we’re using self-assessment tools, survey instruments and interview guides.  

In summary, by using these data sources and methods we will provide a multifaceted view of the influence of women’s health SCAN-ECHO and e-consults on VA delivery of women’s healthcare.  Now I’m going to hand it over to Lori and Kristen to discuss P5.

*Lori Bastian:*Hello, hi, happy Monday.  I’m Lori Bastian and I’m at VA Connecticut and Kristen Mattocks is at VA Central Western Massachusetts Healthcare System.  We are both PIs on this project entitled Evaluation of Quality and Coordination of Non-VA Care for Women Veterans.

Just a little bit of background about the project.  It involves studying outsourced or non-VA care.  This is care that’s used to provide specialized health services that are not provided within the VA.  Examples of non-VA care are things like mammography and prenatal care specifically for women Veterans.

In one analysis 34 percent of women Veterans who were using VA care also used some form of non-VA care.  The number continues to increase on an annual basis.  Despite these increasing numbers of women relying on non-VA care for some of the services that they need little is really known about the quality of this non-VA care.

Our study is going to put a focus on the quality of mammography the reason being a majority of the VA facilities across the country contract with other hospitals and other facilities for diagnostic mammograms.  It seems like an opportunity to study *[audio cuts out]* issue that’s quite common.  How common is it?  In fiscal year 2009, so several years ago, there were 51,396 mammograms in the VA system.  Again the majority of those are done as non-VA care.

Our project has three specific aims.  The first two aims are being led by Dr. Mattocks and they are predominantly qualitative aims.  The first aim being to understand providers’ and fee basis managers’ strategies for providing, coordinating and oversight of non-VA care.  The second aim is to actually talk to patients who have utilized non-VA care and understand their perceptions and experiences with this care that they receive.  The third aim is the aim that I’m leading, and this is more of a quantitative aim in the fact that we are actually going to be evaluating the quality of mammography services for women Veterans.  Comparing those sites that have on-site mammography to those sites who use non-VA care for mammography.  We will be doing that in the form of a large chart review.

I had the pleasure of showing you our study design and our model.  Despite being a little bit complicated the goal of this model is to portray the importance of care coordination being in the center of the figure.  We really want the patient experience to be good, and we want them to feel that their care has been coordinated well.  We know in order for that to happen we need to be able to examine what’s happening on the VA side and on the non-VA side.  We’re going to also incorporate a qualitative measure of mammography to try to tie that together.  I’m going to turn it over now to Dr. Mattocks and she’s going to talk to you a little bit about our sampling plan.

*Kristen Mattocks:*Thanks, Lori.  Across our three aims our goal is to sample around 20 sites or so *[pause]* that vary in terms of women’s use of fee-basis care.  We’ve taken all facilities across the country.  We’ve divided them up into low fee-care facilities, medium and high fee-care facilities.  

**Now that we’ve done that we’re selecting particular sites within those different types of fee care.  In Aim 1, we’re going to conduct telephone interviews with two to three providers and one to two fee-basis managers at each of those 20 or so sites representing different levels of fee care.  Again as Lori mentioned earlier we’re going to focus on the challenges of referrals to and coordination with non-VA care and with a really particular focus on mammography because we think that that’s an excellent case study of fee care in the VA.

Aim 2, is going to focus on talking to women from those facilities who have used fee care in the past two years.  Again a portion of those women are going to have a mammography recently.  The other 50 percent of women we talked to are going to have another type of fee care.  That will likely be a gender-specific type of fee care such as pregnancy care or something like that.

In Aim 3, Lori is going to focus on conducing a medical record review of women Veterans at those same sites with either non-VA or in-house mammograms in fiscal year ’12.  The goal of our work together is to really synthesize providers’ experiences, managers’ experiences, women Veterans’ experiences with actually what’s going on in terms of mammograms.

Moving onto the next slide, we have detailed here our research questions that Lori has spoken of earlier as well as tying those specific questions to some of the conceptual domains we pointed out in our conceptual model.  The goal of what we’re doing is really as I mentioned earlier to get at all levels of understanding VA care for women Veterans.  From what those fee-basis managers are doing at each facility, providers, women’s experiences and understand that in context of satisfaction with fee care and access and utilization as well.

Aim 3, which is Lori’s Aim is going to be looking specifically at administrative data including Corporate Data Warehouse, DSS, text notes, Vital Status Files.  In those chart reviews, she’s going to divide up her work into two phases.  Phase 1 is really going to look at determining whether or not mammogram results are appropriately acknowledged in the medical record which is something we don’t know much about at this point.

Phase 2 is to measure the number of days after an abnormal mammogram which is defined as a BIRADS score of 0, 4 or 5 that results are evaluated and followed up in the VA.  In context of understanding this information we’re also going to collect patient’s age, race, service connected status, body mass index and breast density to understand how these results might vary based on these characteristics.  With that I’m going to turn it back over to Becky Yano.

*Dr. Yano:*Thank you so much Kristin and Lori and everyone.  We specifically held everyone’s feet to the fire on the amount of time they had for each project.  I can imagine that many of you would like even more detail on some of these issues.  We really wanted to make sure that there was time for questions and answers.  Also I wanted to make sure that you had our contact information, and we can obviously get you everyone else’s contact information for specific studies in which you have taken perhaps special interest.  

I also just wanted to make sure everyone knew we have also the benefit of Dr. Hayes online if there’s anything else she would like to add.  We’re happy for your input as well obviously.  I also want to thank Angela Cohen who is actually funded through Dr. Hayes’ office to provide core Women’s Health CREATE Management which really has helped us tremendously in the coordination of across project synergies, opportunities for developing additional projects.  I know it’s already going to be helping us develop core data sets and tools that will expand and leverage what we’re able to accomplish.  I thank both Angela for her time in getting this organized for us and Dr. Hayes for making this possible.  We’re happy to take questions, Molly, at this point any time.

*Moderator:*Excellent.  Thank you very much everyone.  I just want to mention to Dr. Hayes if you can press star zero and ask them to moderate your line, you’re able to come on and make some comments.  In the meantime, for those of you that joined us after the top of the hour to submit a question or a comment just use that Q&A box that’s located in the upper right-hand corner of your screen.

The first question that we have pending is for Dr. Hamilton, regarding attrition what is the rate for male veterans new to the system?  I’m wondering if it’s substantially lower than the 30 percent rate you mentioned.

*Dr. Hamilton:*I’m actually going to defer that question to Dr. Frayne who’s better informed about these things.

*Dr. Frayne:*That rate based on the national administrative data is similar to the rate for women, a little bit lower but not dramatically lower just in terms of raw numbers.

*Moderator:*Thank you for that reply.  Dr. Hayes, do we have you on the call?  We’ll give her a few more moments to get through to the VANTS operator.

*Dr. Yano:*Oh, and I didn’t mean to put her on the spot.  She may have just missed today.

*Moderator:*No problem, I do see her in the meeting.  That is the only pending question we have at this time.  I’d like to encourage our attendees to take this opportunity to speak to the experts we have on the line.  The next question, are you tracking results for women Veterans across various military sectors:  Navy, Army, Air Force, Marines?

*Dr. Yano:*Each PI may want to address that one because they’ll have varying capabilities.  I know for our Project 2 on comprehensiveness we’re looking at the population of women Veteran users to the extent possible.  In so far as period of service is available we will certainly take a look at that as a stratifying factor.  For the third project in Women’s Health PACT we’re also attending to the needs of all women Veterans that are seen at that location.  We don’t have reason to believe that primary care delivery should necessarily and evidence-based quality improvement should necessarily have differential impacts by period of service.  We will certainly have those data and can look at that.

*Moderator:*Thank you.  Did any of the PIs want to touch base regarding their projects specifically?

*Dr. Yano:*I’m actually wondering myself from Project 1, not to put you on the spot.  I would think that period of service would be in the quantitative data that you have.  Is that true?

*Alison Hamilton:*What about branch of service actually, Molly, can you just clarify that?  Was it which branch of service they’re in?

*Moderator:*Yeah, correct.  Oh, I’m sorry they want to know across all sectors:  Navy, Army, Air Force, Marines.

*Alison Hamilton:*Okay, I actually have to go back and double check whether we have that variable through the roster, through the OEF/OAF roster.  It would only be probably for the group who are OEF/OAF/OND specifically.  Thank you for that and I’ll go back and double check.

*Dr. Yano:*I do know that one concern we may have is just the sample sizes that are available by service, by branch.  I think that one of our issues in some of the outcome data has just even been having enough women, period, to look at some of these things by gender.  It may be methodologically a challenge, but we’ll definitely look into it.

*Moderator:*Great.  The same submitter notes that she is from Canada and trying to see if there are differences across the three military sectors.  Their population capture is much more limited than ours in the US, but it would be interesting to know if there are sample size issues.  Thank you for those comments.

We have several people writing in thank you for the comprehensive presentation, and wondering if the slides will be available.  Yes, once again they are available in the reminder email you received a few hours ago.  If you scroll down, there it’s a hyperlink leading directly to the slides.  They’ll also be in our online archive catalog.

All right, that is the only pending question at this time.  I’m sure if any of you have any more comments while we wait for more questions to come in.

*Dr. Yano:*Well, one of the questions from us really is how frequently the audience of women Veterans program managers, women’s health medical directors, women’s health and non-Women’s Health researchers are interested in updates from this?  The CREATE iniative is a major investment on the part of VA HSR&D Service to conduct and accelerate impacts through partnered research.  

Ours was funded in the first round.  I think that there is a lot of interest in how these initiatives progress.  We needless to say have a lot of work to do, but we also want to make sure that if there’s information that’s going to be useful to the field we get it out there to everyone as quickly as possible.  We’ll always be interested in that feedback as well.

*Moderator:*Thank you, Dr. Yano.  Patty, did you get your line unmuted?

*Patricia Hayes:*I’m here.

*Moderator:*Excellent, would you like to make any comments?

*Patricia Hayes:*I want to thank the group for the comprehensive update on the studies.  I think it’s always of interest to have us get some stimulating questions about points that we may not have really tuned into.  I was particularly interested in the one about branch of service.  I think also when we look at men versus women and overall studies we have to be aware of the differences in deployment and non-deployment and things that we can’t necessarily attack in each of these studies.  We know with the age difference that we’re getting differences over the more recent times in terms of which sector that someone might have been in.  

All of these studies of course are vital to us.  We worked with them in terms of high utility.  I was thinking about attrition for men is one that we often take a look at, but for women we know that women have health needs particularly in our younger women’s group where they really should be coming to healthcare during their reproductive years.  They should be coming to healthcare approximately 2.5 times per year.

It’s difficult to compare attrition rates in men and women in the same way.  A young guy may not come unless he has a serious injury or he’s getting polled 48:18 for mental health care.  We are interested.  We’re also interested from the perspective of kind of a flashback on particularly the Veterans perspective.  Is their experience of VA having a role in attrition and that’s our investment in the individual interviews here from our standpoint.

It’s not enough to just get our women Veterans to try us.  We want to know whether we’re doing things that are making them not want to come back.  Attrition studies of course are close to our hearts in terms of being able to change the system.  Many of the other parts of the study are very vital to our understanding of some of our implementation of women’s healthcare.  All of it of course has huge policy implications for us.  We continue to be excited about the opportunity to work on these studies together.

*Moderator:*Thank you, Dr. Hayes.  We do have another question that came in.  Are there plans to coordinate with the Military Health System/TRICARE Women’s Health Initiatives?

*Dr. Yano:*That’s a wonderful question.  We don’t have or I should speak for myself.  I don’t have as direct a set of relationships to actually hasten that kind of collaboration.  The need for greater VA/DOD collaboration and research development in this area has been identified as a priority.  If the person who posed the question has recommendations, we’d be happy to hear about them.

*Moderator:*Thank you for that reply.  Our submitter does have the contact information so they can feel free to contact you.  The next question, what barriers and/or challenges do you anticipate in trying to capture a representative sample of women and being able to do adequate follow up over time?  Are Veterans with more years in the military more likely to be captured versus those with fewer years?

*Dr. Yano:*Boy, that’s a great question.  I’ll defer to some of my other colleagues with the one proviso of we found actually that we’ve had pretty darn good response rates.  Actually Dr. Washington, I won’t even steal her thunder for a moment.

*Donna Washington:*Sure, this is Dr. Washington.  I can reflect on the experience we had with the National Survey of Women Veterans which actually was cofounded, primarily funded by Women’s Health Services and also funded by VA HSR&D.  In the National Survey of Women Veterans we had an overall great response rate of the women Veterans that we were able to reach by telephone and screen for participation.  Eighty-six percent of those who were screened and eligible participated.

We included both VA users and non-users.  There was a slight difference in response rates so we found that we had a better response rate among the VA users compared with non-users.  Then in addition the response rate was somewhat better for older women Veterans compared with younger women Veterans.  I think that the one thing that’s common across the five Women’s Health CREATE Projects is that we’re all focusing on women Veteran VA healthcare users.  The experience of the National Survey is favorable with respect to what we hope to accomplish.

*Moderator:*Thank you for that reply.  That is the final pending question we have at this time, again lots of thanks coming in for the great session.  Would you guys like to give some wrap-up commentary?

*Dr. Yano:*Anything my colleagues would like to say in terms of their individual projects or perspectives?  Okay, hearing none I just need to thank everyone both who’s listening because you’re an important audience for us, but also my colleagues that are the PIs and co-PIs of these particular studies.  This was a two-year gauntlet as I’ve called it in terms of the proposals and processes as we were working through the initiative with VA HSR&D Service and our partners.  They’ve been a tremendous set of colleagues and I’m very excited about the opportunity for impact on women Veterans care and experiences through this process.

We look forward to providing you with updates over time.  We wouldn’t be here without the collaboration and the partnership that everyone represents.  That’s it for me.

*Moderator:*Thank you.  Well, I’d like to echo our thanks to our audience for joining us today as well as Dr. Yano and all of her collaborators for joining us and sharing your expertise with the field.  I am going to ask our participants to stick around for just one second.  I’m going to close out the meeting and a feedback form will come up onto your screen in just a moment.

Once again you do have their contact information in the handouts.  Feel free to get in touch with them if you have further follow up.  Thank you once again everyone for joining us and have a great day.

*[End of Audio]*

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