**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**Strategic Plans in Women’s Health-Implications for Research and Program Evaluation**

**Presenter:  Patricia M. Hayes, Ph.D.**

**February 13, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact patricia.hayes@va.gov.*

Moderator:At this time, I would like to introduce our speaker. We are pleased to have Dr. Patricia Hayes joining us. She is the Chief Consultant for Women’s Health Services in the Office of Patient Care Services for the Department of Veteran’s Affairs. So, at this time, I would like to turn it over to Dr. Hayes. Patty, you are still on mute. Patty, I am not getting any audio from you. I am not sure if your telephone is still on mute, or if we have lost you on the call. Oh, there we go.

Dr. Hayes:Is it working now? I apologize.

Moderator:No problem, thank you.

Dr. Hayes:Having some Blackberry difficulties. But, the good news is I do not have to touch it from now on, so hopefully, we will be able to go forward with the presentation. Good morning and good afternoon. Thanks everyone for joining us. I see that we have 84 attendees and that is very gratifying. Today I am going to talk about really an update to a program that occurred two years ago, and talk about the strategic goals and priorities for research based on the activities in my office in VACO as the oversight on women’s health delivery in the U.S. for Veterans.

As a reminder, it is important to understand the population, one I have described as the pipeline. Active duty, 15% of the active duty are female, 18% are National Guard and Reserves. And, we have already seen increasing numbers of women coming into VA based on this increased number in active duty. Of the current deployments, 11.6% are female Veterans, and we have gained slightly to 6.5 for VA healthcare users. I pay less attention to that number, because the denominator keeps increasing, because of the male Veterans coming in from deployment as well, so it is really not a good indicator of our growth. 

And, I think that one needs to think about the changing face, even over the last couple of years, obviously, an influx of younger women from the recent deployments, frequent visits, and I think increased enrollment. We know that 60% of those who have recently served have enrolled in VA. This is a huge change from earlier groups of Veterans. We know that most uses more than 11 times, meaning the engagement in primary care. And, you will see later from some of our evidence that they are averaging a high number of visits per year than our civilian counterparts. They come in with more claims and awards of service-connected disability proportionately. Obviously, maternity care is a growing area. Women and young men who come with us are usually working and have restrictions on what they are able to do in terms of participation in healthcare. And, they have many complex co morbidities, including mental health needs. We have about 31% of them having a burden of mental illness diagnosis. They also have a series of complex co morbidities. 

We also see the changing face of the VA in that aging women are actually still our largest sub-population if you look at those over age 45. So, we have lots of young women, but our largest sub-population is still our aging women. And, the group with the greatest gap in market penetration, and I am not going to talk a lot about market penetration, but right now, for women it is 17%, meaning 17% of all possible users are using us. So, I just told you that 60% of the young group come in, but our overall market penetration is 17%. So, it is obvious to me that the gap is in the aging group. We have their needs in terms of menopausal needs, geriatric care, inpatient/extended stays and things that the VA does not provide like assisted living, pain management and certainly probably one of the highest issues of conditions in this group, and then the emotional issues as women age and their partners dies before them for grief, loss and isolation.

I want to make sure that you understand our mission on this. I always think that it is important to be clear that we know that women receive equitable, high-quality and comprehensive health care in a sensitive and safe environment at all VA facilities. And, we want to continue to be a national leader in the provision of health care for women Veterans, raising the standard of care for all women.

The strategic goals of women’s health in the VA central office and for the country. Number one is to transform health care delivery for women Veterans. Second is to develop, implement and influence VA health policy as it relates to women and also this means not just our policy in women’s health, but all the policies. We take a lot of time on that issue. We want to develop, implement and influence VA education initiatives, and we are driving the focus and helping to set the agenda to increase the understanding of the effects of military service on women Veterans’ lives. This really certainly is where the focus on research integration lies. We constantly want to support and set a focus on the highest utility research. And, from our perspective, the utility is for evolution of our program, greater understanding of Veterans and women Veterans and improved outcomes for women Veterans. So, the areas that we are thinking about are things that have to do with the program and a true understanding of the effects of military service. One of the areas that we still are not doing a lot on are the positive effects of military service, but I leave that for some of you to think about.

The goal one is transforming health care delivery, and obviously, a lot of our effort has been implementing a new system of care for women Veterans, focusing on comprehensive primary care. And, the definition of comprehensive care really includes all of these elements. I am not going to read all of them. I think sometimes people still need to be reminded that we are going for the PACT model in a one-stop shop kind of approach, so that working women and others can have more efficient care. We want to make sure that their chronic illness and their acute issues and the preventative services, including gender prevention are all covered in the primary care venue. And, most recently, a lot more focus on mental health services, and the last point I will pick up on again in a moment, which is how we measure the implementation of women’s health. 

When we first started doing it, we knew we needed to have a lot of different data sources to be able to follow what we are doing in women’s health. So, the first is, the two go together, the WATCH, which we will talk about, and the site assessment tool, sometimes referred to as our Bruce Allen Hamilton tool, because it is a contract with the help desk. In developing the assessment tool, we have been doing approximately 20 to 25 site assessments per year, now in our 4th year. The tool itself, and I go a little bit into these items, because I think it is interested, the research is important for you to understand that we have data available, which people can tap into and think about in terms of what you out there may want to look at, in terms of women’s health and HSR&D projects. So, the site assessment tool, we have an annual report which is on BSFC, and we have been rolling up trends in the capabilities and this really is about the capabilities of providing health care to women. We this year did a re-evaluation of the tool and made some changes, but from year-to-year there is a lot of items that are consistent.

From that tool, we also developed what is called the WATCH, the Women’s Assessment Tool for Comprehensive Health. It is self-administered by the VA at each facility, and rolled up by divisions. We do have data for ’11, ’12, and ’13, and the ’13 data is still being worked on, but I think it is important sometimes, and we also, by the way, have a comparison between self-administered capability and reliability based on the site visits and some data on that. But, they are really two different, the way they are administered, they are two different tools. It does help us look at a lot of data though about what exact type of services are available for women in each and every VA and CBOC. Another area that it is important to understand is all of these are available on the VSSC sites and we have developed a number of workbooks on VSSC. But, one of the workbook sites has the WATCH tool, data and capabilities, the model of comprehensive care at each site and data on the number of designated women’s health providers.

A little bit more on the WATCH, it should say 2012, but I picked some data here from 2011, just to show you what is going on in terms of probably the most frequent question that is asked, which is the number women’s clinics that exist in the VA. And, those who follow our work may recognize that we shifted from the definition of a women’s clinic to how care is delivered and primarily focuses on the type of provider delivering the care. But, if you look at our policy, which is 13.30.01 and it is referenced later here, we have a definition in 101 clinics are highly integrated with primary care, Model 2, are women’s clinics that they share space. And, Model 3 are the clinics that were traditionally seen as comprehensive women’s clinics. Just an example, but if anybody wants to work on this type of data, we have our own in-house experts who would be happy to help you with how you can apply WATCH data to investigations of the type of care that is being provided in the VA. 

Additional data sources for areas of interest are PACT *Women’s Health* clinic assignment in PCMM, it is actually the team-led assignments. So, regardless of how many women are in a provider’s panel, or the percentage of women in provider’s panel, if the provider is a designated women’s health provider, then there is this PACT designation. And, we learned today that PCMM is having a new version, and that is the clinic management system for those who are not familiar with PCMM. But, there is a new version coming out this summer where this provider assignment is going to be refined based on the women Veterans the providers seeing. So, since we have been looking for a long time for ways to cross-match the patients and their outcomes with the type of provider or the training and proficiency of the provider who is seeing them, these movements forward in identification of women’s health providers are critical to our ongoing examination of data. And, I think that when you think about all of things that are going on, even though they may not be seen as women’s health, different types of clinical health activities, things like interpersonal violence, where folks may be wondering about, as these efforts are going out, how can we look at various types of experience of Veterans and the activities of the provider. The fact that we can identify our providers is really very critical.

I sometimes find that researchers are not familiar with VSSC, and I am sorry I did not put the cite here, but we can add it. The VSSC is essentially another data warehouse for VA. The advantage of VSSC is that you can go into a software called Proclarity and essentially do soldiers and sorts. We have workbooks for women, which include women enrollees and women users and the specifically excluding employee health business, which is a critical element for doing research on women. There are also a way to look at all the diagnostic categories from encounters and on soft purge data. One of the advantages of VSSC is it is almost real-time and it is updated nearly every 24 hours, and so if you are looking at the way you want to compare points in time and have updated data, VSSC is one of the sources that we use very frequently. It helps to also look at, if you were trying to identify an area in which you wanted to conduct research on women, and maybe a site is one of the sites in the PDRN, the Practice Dates Research Network, you can go to VSSC and find out what the population of women at that site is. And, also the population of women in certain age groups, for which certain diagnostic conditions, by using the VSSC. So, you would know where you might want to target your efforts to recruit women from one of the PDRN sites. I think in that way, it can be very helpful to you.

And, then very, and I’m very enthusiastic and grateful for, actually I see that Dr. Susan Frayne and others are on the call here, for the Women’s Health Evaluation Initiative. We continue to work very closely with Dr. Frayne and Kim Phibbs and all of the team at Palo Alto to produce a number of things. We, they continue to work with the entire dataset from Austin, you have  [inaud.] files, you have [inaud.] files in order to identify women Veterans, male Veterans. They have helped us to identify and define a great number of variables, including race/ethnicity, something called, we are calling conditions, which are groups of, types of diagnoses, rural and urban factors. And, we worked now to develop [inaud.] agreement processing so that if you want to be able to tap into this resource for the research, it is quite available now. Obviously, a process we want to make sure how the data is being used and [inaud.] use.

I will talk a little bit more about the sourcebooks in a minute. We also have developed a list of those that are designated women’s health providers in the VA. So, a designated women’s health provider is someone who if proficient and interested, who is assigned to see women in a primary care clinic, and we have a list now that is verified at the local level. And, you can see that this was from the ’12 list that nearly every medical center has at least one. And, we do not think this is enough, but we know they have at least one. The health care systems, medical centers, those are two different definitions. And, as of  ’12, 75% of our CBOCs had at least one. Now, they are now seeing exclusively women as we’ve stuck to the models of care. They may well be seeing only a smaller percentage of women at their site, particularly the CBOCs, but they have met certain criteria locally to be a designated women’s health provider. So, in addition to the other ways in which we look at who are the folks that are providing care to women, we have this other list that we are working with. We are already data and have soon to be presented some data on patient satisfaction based on the designated women’s health provider. And, we are doing some clinical performance outcomes, but there is a tremendous amount of room to do additional and innovative performance outcome data and behavior data for clinicians, based on the designated women’s health provider.

So, when we think about implementing comprehensive health for women, we have moved beyond the fact that we had to implement primary care. Most of what we talked about in the data sources are specifically related to designated women’s health provider providing primary care. But, as we look at things like narrow gender disparity, like the issues of women at risk for cardiac disease persisted, we recognized that we had to develop a workgroup to look at the provision of cardiac care for women in the VA. That workgroup has already been collecting data and actually is putting out a white paper very soon on cardiac care for women. And, I would, we will put that on our website. And I would, those who are interested in these kinds of issues for women, I think that is really a jumping off point for exploring some of the findings and look at how we can improve the care of women in cardiac disease. And, you know, of course, this is another are where other systems have not really addressed so much the gender disparity. They talk about knowing that care is different for women and the American Heart Association were working with in terms of actually making it different and implementing changes in that area that we very much want additional interest and research in.

Another area that we had previously not done a lot of work in is we are looking at breast cancer women. VA has a very good track record of doing screening mammography, but because most of our care is fee-based out, we have not had much data on what happens after the screening mammography. So, we have developed the first two things, which are IT projects, tracking of abnormal test results is in a bit of a delay, but it is underway, which we will start with the ordering of an abnormal test and allow providers to intervene and to follow what happens. The first case will be a mammography result. The next thing is a Brest Cancer Clinical Registry, which is in a beta format right now in IT and it will soon be released, being able to track from the abnormal breast cancer finding to a case registry and being able to tap management reports. Which, again, anytime we have this kind of data, I think it opens the door for additional research on all kinds of things from how well our mammography coordinator is able to perform their duties, to how well do we track abnormal test results and what is our time to treatment looking like in the VA. And, then because of issues of so many different ways to provide care and so few standard operating procedures, we have a breast cancer workgroup now conducting surveys, which should soon be released. A survey about equipment, about who is providing breast cancer care and all the things we think about in terms of the delivery of care around the issues of breast cancer.

We also have an extended focus on non-VA care evaluation, and while there is one project underway about the quality of care, this the brand new launching of a PC3, which is the new contract for providing overall non-VA care in the VA. That is launching across the country right now. It is the perfect opportunity to kind of get in on the ground floor of evaluating access to care, quality of care, turnaround time, reports and evaluations, and how people are able to participate, kinds of provider or the patients receiving this care now that we are going to have a whole new system of non-VA care in the VA. And, then another area that we are expanding constituted with the fact the VA is looking at productivity measures for GYN care and we are involved in that in terms of what is GYN care. And, we do believe that there is a necessary allotment of GYN care in the VA, but we are kind of caught up in the productivity and efficiency issues. So, there is an area of focus.

We also have comprehensive health issues which have high morbidity and mortality risks, which are just getting off the ground. Lung cancer and smoking women, you may know that it is, after cardiac disease, it is one of the highest mortality issues for women. There is no current projects underway. There is a new lung CT pilot that is getting launched in VA and right now we have no foothold for evaluating any of that by gender. Colorectal cancer screening the VA, I know of no research going on about that for women. So, that is another area that we would be very interested in. And, interpersonal violence, we know the VA has new research underway. VA has new policies, standing up a new screening, there is new practice going with points of care at each medical center. There is going to be all kinds of education and training, and I think as we talk about implementing a new type of practice, there is lots of room here for research that would help us elucidate this issue.

We are also, underneath what we are doing in large strategic focus, we are also expanding in reproductive health. And, just to give you an idea of the areas here, we are already focusing on preconception issues. We need maternity outcome data under healthy pregnancy guidelines and looking at the VA pre care and how the records are coming back in. How are we going to look at maternity outcome data? We have a very large project on reproductive mental health, which includes everything from a new curriculum to the possibility of telehealth consults, telehealth, mental health consults on reproductive mental health. Maternity care coordination was launched about a year ago with the required designee at each medical center. That is just being implemented, and it is actually not really much definition, nor is there any structured look at what is that maternity care coordination adds in terms of the follow-up for our women Veterans. And, then we go back to things like maternity outcome data, and looking at depression, post-partum, and looking at a lot of different things that we need to look at for maternity care. And, I think overall when we think about—we could put this on every slide—but, the implementation and diffusion of best practices. We do, we can, our office have ways that we are trying to get best practices at, but I think a huge question for VA in general is when we do RFPs or we do a lot of pilot work, how can we really diffuse, how can we incentivize it or how can we support it. What are the best ways, really, to do best practices. So, there is a lot of implementation science, but I am not sure that we have this drilled down to a level of what are the ways that people are really hooking in and diffusing practice. And, reproductive health is probably our strongest link with DoD, and so for those of you that are interesting in working through some issues with DoD and getting information on DoD, we are beginning to have those links.

Now, see not just babies, because reproductive health is through the lifespan. Our focus this year has been the VA emergency medicine for women, including all kinds of topics like abnormal bleeding, cardiac care and mental health care. Recent educational efforts, we are looking at it as interdisciplinary team training and, of course, this is an area where outcomes and sort of pre and post-test changes in behavior, changes in women using the VA emergency rooms, all kinds of possible outcomes here. Reproductive health, we are looking at aging issues, menopause care, urinary and incontinence issues, urinary and incontinence issues. We are just on the cusp of providing toolkits and best practices for clinic approaches. And, throughout the work we are doing, we are using a lot of telehealth. And, so we have new telehealth efforts in precepting, new telegyne, telecolposcopy. And, I think there is a lot of room for looking at patient perceptions in telehealth, provider perceptions, uptake of telehealth, cost efficiencies, other efficiencies, and again, trying to get the voice of the Veterans in terms of what are real telehealth outcomes.

We want to also cover VA health policy. I just have a couple of quick slides on this. I think one of the things that we have spent the last seven years on really is developing, enhancing the language practice and culture of VA to be more inclusive of women Veterans. And, I know Dawne Vogt and others have done some work on culture sensitivity, and I think that, for me, there is an open question about can we measure any of the effect. And, particularly, of course, even sort of so we can pat ourselves on the back and say we have done some nice posters. But, what is the impact for women Veterans on the perception of VA care. And, we know that there is a lot of misperception in the world about VA care and how could the culture change campaign effect outreach and enrollment by age cohorts, and what is the effect on VA workforce. So, these are critical questions that I would be very interested in discussing with someone about additional research.

I just wanted to go, you know, we talk a lot about the 2008 report as really the foundation, recommendations became policy, and this is where we think about influencing policy. But, if you want to look at 1330.01 in terms of the implementation questions, it does define what you must do, primary care, designated women’s health providers. As I said, it does—I am sorry, this slide is really a little out of order—but, it does establish some kinds of data collection processes locally. 

Okay. We will talk a little bit about our education effort. You have heard about our mini-residency. We have now trained 1850 folks and used an education model that has been adopted by others. We have moved with that, we continue to do that, and we actually have some opportunities for looking at people who take it live and those who take it online, either in CMS or in our virtual campus. We have a lot of SimLEARN, the SimLEARN project has probably been most delayed by lack of construction in the Orlando SimLEARN site, but we have used a lot of past trainers. We have not gotten any research on the development of past trainers and the use individually versus group, the use of past trainer versus live models, all of the questions that come in terms of outcomes for an individual who is taking this education. We now also have engaged in a tremendous amount of our curriculum being on My Vehu campus. I have a slide on that on one of the other slides. We continue to do topics on PMS. I think for some people it is kind of a bad word is, we use other systems like CMS usinf Adobe Connect. I think that there is a real question about the effectiveness of education through the various modalities, and is it different for different subsets of our providers and nurses and staff trainers. Is it different for different kinds of topics. We most recently have launched, as I said, the emergency room training, the My Vehu campus, because of its 24/7 easy accessibility and knowing that emergency room providers are frequently not taking trainings during the day or at remote sites where they have to travel. But, some of those factors going into really the issues of the best way to provide training and education proficiency and competencies for VA staff. I mentioned we have new curriculum on reproductive mental health. We are rolling that out both live TMS and then some of our systems will be on My Vehu campus. We continue to provide monthly provider audio-conferences, and for those who have not seen it yet on the HSR&D site, there is a call for abstracts for an upcoming VA Women’s Health Research Conference, now I think late summer, but the call for abstracts is out, I believe. And, you can, we welcome our VA researchers to participate in that.

Continuing in this year, we have focused on nursing education. As I said, women’s health provider, and you can look at our most recent emergency room curriculum. If you have not seen My Vehu campus, you need to go there, search the word women. You will see some amazing training that you would like to take on, get your CMEs on any topic you need to get it on. But, last week we did cardiac care for women in the emergency room, and bleeding. I think those should be out very soon, so, if not, if they are not out today, they will be soon. But, there are about 30 or 40 other courses that you could take on My Vehu campus, and we see that as going forward. We also continue to provide innovative education grants and telehealth pilots. We have a goal, a strategic goal of having at least one telehealth project in every division, and at least one rural health telehealth project in every division, so you—we have grown from 2% of telehealth patients being female. But, we still have not even begun to reach the population levels in telehealth that we need to show, you know, what is going on in telehealth. 

And, I have already been talking a lot about research, but we are—a major goal of the office is to drive the focus and set the agenda, so let us talk a little bit more about some of the things I have talked about. Ongoing is the Women’s Health Evaluation Initiative with Susan Trane [PH], and with all of our great partners in Palo Alto. And, you can direct email questions to me and to Susan Trane, if you have things that you want to know. The next slide is about some of our output there. The Practice Based Research Network, the Women’s Practice Based Research Network now encompasses over 100,000 women potential research participants. And, a great number of sites in the VA and that is successfully driving research. Some of the studies, obviously, they are already ongoing, are post-deployment health, combat and trauma exposure, lots of gender-specific, reproductive and mental health conditions. If you have not seen it, it is now a little bit dated, but it is a live abstract search for the systematic review, and is it on this slide. It just started being kind of a strong partner. 

The Women’s Health Evaluation Initiative has now published two and soon to be three of our sourcebooks. Volume I: Sociodemographics and Use, we put it here the fee basis data. The challenges that really were overcome were data quality issues, employee versus Veteran data, some of the issues about change over time. It is available electronically on our site. And, again, gratitude for the tremendous work there. What is particularly of interest to researchers are the technical appendices in this one, and in the following versions. Just a couple of slides, I am going to go quickly over some of the things that we found very useful. Intensity and proportion of mental health use, and mental health visits for women Veterans. Women using mental health more than men proportionately so, and intensity, again, how many women have lots of mental health visits increased in proportion over time of women with service connected disability. We actually think this is a function of both a change in culture in the VA, more exposure to jobs in the military in which injuries are more common, and also I think some listing of stigma for women about reporting certain kinds of injuries. And, this is the one that shows that of the women who use VA, there is a higher percentage, 56% have a service-connected status. I think that is a point that when we talk about VA and our mission, it is a really important focus, probably why I included this slide. 

Sourcebook Volume 2, as I said, sociodemographics, use of non-VA care, urban and rural comparisons, much more is in there. But, I wanted to make sure I got the link up there. We also have a hard copy so if people want to be able to access them. And, Volume 3 is just about ready to go into concurrence and so we will be releasing it a little bit later this year. Volume 3 has a lot more information in about various groups of conditions in women.

And, some of the other research that is going on, I actually had a typo here, and there are only 8,000 participants. I wish there were 38,000. There are 8,000 participants through telephone interviews. This is a national study that we were required to by Congress, but we are thrilled that it is quickly going forward. Many of those participants’ interviews are already completed. So, a lot of the barriers to care for women, also important in that study is it is stratified by division, and must be at least 400 participants per division. And, there is some other stratifying factors in the randomization, so that we look to kind of applicability of that study as it comes out. And, the access to date afterwards, so the access to some of the data points. The Women Vietnam Veterans Study should be coming out pretty soon, and additional studies from the West Haven Yale OEF/OIF Cohort Study.

So, what do we need more research on, and I am going to go through this, a couple of quick slides that we will also get at some of the points I have already made. And, then I will have time for questions. We continue to need more research on how we have been implementing changes in the VA system of care. We need to look at providers, we need to look at the development of PACT and women’s health PACT. We already have some data from the WATCH that suggests that staffing is not equal in the women’s health PACT, that access to mental health care is not the same in the women’s health PACT as in the other PACTs. There are many other questions that when you just have access to the data on PACT implementation, I think one can look at those comparisons. 

And, then generally, I think issues for patients, both in PCC, which is patient-centered care, and there are quite a few patient-centered care innovation projects, in innovation labs going on in the VA. I have seen no data or descriptions even of patient-centered care with involvement with women Veterans or perceptions by women Veterans of the patient-centeredness initiatives. I think we have to look at the comprehensive health care outcomes. We have looked at some of the prevention outcomes, but not overall health outcomes, and we certainly are going to continue to look at all of our subgroups. We have continued to express that women are much more racial and ethnic diverse subgroup. But, also we know that geography is an issue and access to local health care. We know that with the work of Cory Bird [PH] and Rand [PH] we are able to look at zip codes and look at availability of all kinds of health care, everything from the number of, you know, drug stores, churches, local primary care settings, VA care settings, and health care outcomes by geography. So, as we get that data, I am encouraging folks out there to think about how would we like to look at this. And, when we think about the women’s health program, it does not make sense to push the VA to make the same exact program everywhere. But, rather to meet the needs of the Veterans who are in that geographic area. An example being that in upstate New York there are very few young women Veterans. And, although we have to have minimum services, there is an aging women population that has different and in some ways greater needs. So, when we think about looking at our implementation care, our structured care, our delivery of care and our outcomes, we got to be thinking about geography.

Telehealth efforts, I mentioned that with the wide extension of telehealth and virtual health, we really need to know about all the delivery of care, what are the outcomes, what is the patient perception both before they engage in telehealth and after they have received telehealth. The various types of telehealth, what do Veterans want, you know. Do they want Smart phone, do they want iPad, do they want to go into a site where other supportive people are around in a clinic and receive certain kinds of care? And, what is their level of engagement and understanding? I do believe that VA will not be building any more great big hospitals. We are going to build some big out-patient, you know, mega CBOCs in some places, but a large part of our health care will be delivered in more technical and telehealth ways. So, this is really vital research for us, for men and women both.

I already talked a lot about education outcomes, but with all the education effort that we are doing, we certainly would be very interested in ways to study outcomes. And, diffusion of best practice, I already talked about how we are doing a lot of work with, doing a lot of innovation, what really is the structure of delivery and best practices. 

The other, some of the other things that when I was thinking about doing this, I think, these are some of the areas that are really not being studied yet. There is access by gender, there is lots of access data we do not yet have access data by gender, meaning, you know, delays in access, what are really the capacities of systems to deliver care. Again, geography, targeted outreach by age, I mentioned how our gap is in participation by women as in the older age groups and we do not even know how to reach those women. We were talking recently about finding some women, but not even really asking them how did they find out about VA. Awareness of VA care and services for women, you know, that is part of the targeted outreach. We need to continue to evaluate our issues and our policy about comprehensive care, both in terms of what is needed, care delivery preferences. We continue to move forward with not enough voice of the Veteran in terms of what works best for them. And, I think in our partnerships with health care equity and quality, certainly in what we support in terms of investigations over the next year or so, are our requests for proposals will have the opportunity to have some folks to examine equity, not just gender equity, but race/ethnicity equity at the same time as we do other innovations in health care. And, we will be continuing to partner with the Office of Health Equity to do that.

So, with that, I think we are open to comments and questions. I think sometimes it is the comments by the participants are also helpful. I know they are helpful, so, Molly will be opening up to typing your questions, and go ahead.

Moderator:Great, thank you so much. I know the majority of our audience joined us after the top of the hour. So, I would like to let you know to make any comments or questions, simply type it into the Q&A box that is located in the upper right-hand corner of your screen, and we will get to those in the order that they are received. The first question that came in, running data on patient satisfaction, what is the source of that data and do you have it out—I am sorry—do you have it at the provider level? That is regarding the DWHPs running data on patient satisfaction.

Dr. Hayes:Right. We have a couple of investigators looking at the Shep [PH] data by gender and by facility. And, we are beginning to be able to attach that provider. But, that is a difficult link, and I can refer that, those folks, can put something in the question answer afterwards about contacting some of the researchers that are doing that work. We would like to continue to support Shep data in that way. Also, some local sites are using pre-approved O&B approved satisfaction questions, and giving out satisfaction surveys. So, that is a local option as well. There is already a set of satisfaction questions that are O&B approved that a researcher can use.

Moderator:Thank you for that reply. The next question we have, Dr. Hayes, thank you for the information on the range of your educational initiative. Could you speak some more about how you approached the task of assessing the education needs of VA providers and how you selected or prioritized the particular programs you developed?

Dr. Hayes:I should have Dr. Veet talk about this. She is my education director, but we did do a fairly large needs assessment for each group. So, when we went to do primary care, hundreds of participants that helped us in the needs assessment. We completed a needs assessment for reproductive mental health with mental health providers and, again, I think there may be as many as six hundred people responded, rating their interest, not only in the topic, but in their preferred methods of getting the training whether it be local, face-to-face, cyber seminar, etc. So, we have been, and again, with the emergency room, we’re doing a double assessment of staff and providers and also our emergency room expert team thinking about what they thought most needed to be presented. You know, what were the key topics. We often have to carve the topics down, we had to choose ten for our first series for the emergency room. But, I can refer you to Dr. Lori Veet for more information on exactly how those needs assessments are done. But, EES does help us with that.

Moderator:Thank you for that reply. The next question, thank you for the presentation. You mentioned that you put our requests for proposals. Can you clarify how that process works? Are there requests for proposals that go out regularly, and where can these be accessed?

Dr. Hayes:Yes. The office puts out requests for proposals for innovations in health care. And, they can have an evaluation component. We put them out in comprehensive care, telehealth, rural health, reproductive health, emergency room and they go out every couple of months, they go out via a memo, to 10N and the key person is the women Veteran program manager at each site, and the women’s health medical directors. But, they also are always listed on our SharePoint and on something we call our roundup. So, we can think about maybe HSRD, they can help us with how we can blast this to HSR&D list when we do them. These are not specifically targeted as research proposals. They have program evaluation elements.

Moderator:Thank you for that reply. I am new to the VA. Does your office directly fund research efforts, or does it partner with HSR&D, or R&D to provide the RFAs?

Dr. Hayes:I do not directly put out RFAs. We work very closely with Linda Lipson and others at HSR&D on the women’s portfolio and they have been, I do not say we partner, I think they, we partner because we are very closely aligned. They are very clear on their agenda supporting women in the research agenda. And, so all of this comes, funding all comes from HSR&D or Office of Research, ORD.

Moderator:Thank you for that reply. There was a story a year or two ago about a baby born in a VA hospital. Is the VA planning on including labor and delivery services in VA hospitals, or was the birth at a combined hospital such as Lovell or Vegas?

Dr. Hayes:The birth that was in that story was at Salt Lake City, where they have prenatal care up to about, well, they actually have entire prenatal care at Salt Lake City, because they have OB-GYN on staff and the birth was actually down, literally down the street at the university hospital. We have three sites, Lovell being one, Greater Los Angeles, which does prenatal care and birth at the university in Salt Lake City. We do not have the critical mass of women who are pregnant at the same time at any one VA to provide quality OB-GYN delivery on site at any of the sites. We can look at this five years from now. It is quite likely there will be other VAs that do delivery on site. But, we do not, we are not planning to structure it that way, because highest quality OB care, and not every, I mean, not only do we not have enough at any one time, but live without a half hour to an hour of the VA where they would be delivering at, that being their local hospital. So, when you look at the dispersion of Veterans and the lack of a critical mass, we are not going in that direction now. I would not be surprised though if we, if people in women’s health clinics do start having midwife clinics or other kinds of OB-GYN preconception care at our largest, you know, Texas, Florida, San Diego, places like that that have a very large population.

Moderator:Thank you for that reply. We have got a nice long list of pending questions.

Dr. Hayes:Oh, okay.

Moderator:No, I was not...

Dr. Hayes:I cannot see the questions, so I will, yeah.

Moderator:No problem, we have got about eight pending. Are there plans for future cooperative women studies. If yes, will researchers from other VA facilities be invited at a site?

Dr. Hayes:Well, I do not have the plans, but I certainly encourage and support cooperative studies, and we can help people get together. If you have an idea that you want to do as a cooperative study, let me know. We will try to put people together.

Moderator:Great. What are the sources of funding for “needed research”, i.e. education outcomes, diffusion of best practices, etc.?

Dr. Hayes:There is a possibility of some support from my office for program evaluation, education outcomes, things like that, and there may be some other ways to get that kind of work underway. The other source is HSR&D.

Moderator:Thank you. We have somebody that wrote in saying they are interested in receiving the needs assessment. Where can they access that?

Dr. Hayes:That one is not on a site. We will have to get their email and we will have someone work with them directly.

Moderator:Okay. For the person who wrote that in, just go ahead and type in your email address and I will pass that along. The next question, as more active duty military women are serving in operational billets where health care is delivered by non-licensed providers such as medics and IDCs with little experience with gender-specific health care, is there any initiatives looking at the perception of care received during active duty and how this may prevent women from accessing the VA services as they transition out of the military?

Dr. Hayes:Well, I cannot really answer the question about the transition part. I do know that there is an Army report on care of women and the DoD is stepping on this. There is a new Surgeon General in the Army. So, we see this changing, but it is a really good question. I do know that I can go into more depth at this point about it, because we really not able to control what DoD does, but we are working on it.

Moderator:I know the attrition rate is a big concern. Are interventions for that being studies and evaluated?

Dr. Hayes:I would point that person to Dr. Susan Frayne, who is part of the CREATE project, has a study on attrition in women, both qualitative and quantitative and they can tell you what they are doing. Because, I think it is a very good question that we are worried about. If women come, why do they leave us?

Moderator:Thank you. I would also like to direct that person to our archive catalogue. They actually just did a presentation on the CREATE initiative and they outlined that study in detail.

Dr. Hayes: Thank you, Molly, yes.

Moderator:Are the women health services and researchers also looking at the challenges and obstacles faced by facilitating WVPMs in affecting all the initiatives coming from women health services and other departments in central office which affect women Veterans’ care? For example, no admin or program support assistance.

Dr. Hayes:Yeah, we have a couple of efforts. One is really going to be a survey, the needs and issues for the WVPM, and the other is from an administrative sample, and I am actually working with HR and workforce planning to address what is going on with the physician. So, yes, we got a couple of attacks going on there.

Moderator:Great. I am new to the VA. How does one become involved with any of the workgroups? For example, the breast cancer workgroup?

Dr. Hayes:That one was essentially by invitation, but I think most particularly, talk with your women Veteran program manager and medical director. If they are not already looped in, they can help you figure out ways to loop in with some of us, and email us about your interest.

Moderator:Perfect. You mentioned OMB as pre-approved satisfaction questions for use at local facilities. I am wondering if there are any gender-specific elements of those questions, or are they general satisfaction questions. If you know about that, where could you point us to contacts who have more information about these survey items?

Dr. Hayes:Yeah, there is an OMB white paper. We will have to get you the link. There are no gender-specific questions.

Moderator:Thank you for that reply. Moving right along, we just have a few pending questions. Okay. Any thoughts you can share about whether and how you might evaluate the impact of your educational programs for VA providers? For example, benefit on patient outcomes, greater adoption of best practices guidelines, etc.

Dr. Hayes:I am not sure I quite understand the question. It would be how we would evaluate the outcomes?

Moderator:Yeah, how you would evaluate the impact of your education programs for providers.

Dr. Hayes:I think they outlined a couple of them. I think that we also have a tremendous dataset so that if you want to look in that, you know, of primary care, you might want to look at prescribing practices for contraception before and after, or consult patterns before and after to GYNE, which is not necessarily an up or down. It might be they get better at picking out certain things, so, but it has to be structurally. Look at what was the target of the education and what were the outcomes, and then I think we have access to measure some of them.

Moderator:Thank you for that reply. We do have several more people that wrote in with their email addresses to get a copy of the needs assessment, so I will be sure to pass those along. Next question, have any specific studies been done to examine sex and gender differences in military occupational health issues? For example, musculoskeletal injuries, experience of PTSD, etc.

Dr. Hayes:There actually is a military website that is military morbidity data, that is open to anyone. And, it has actually quite a bit of data on there about the morbidity, and we talk about musculoskeletal injuries, urinary tract infections. There is all kinds of data on that, on mil.gov. So, that is another website, obviously, we will have to find for you. I am not at my regular desk today, I am on Blackberry, so, we will just have to get the stuff back to you.

Moderator:Sounds good. I think that is the final pending question. Would you like to give any concluding comments?

Dr. Hayes:That is, I certainly appreciate the wide range of participation today. I am actually a little surprised that so many given what is going on in the weather setting. But, I think, you know, what I really want to do is stimulate conversation. I want people to think about how we can include women and outcomes in the work that you are doing. If you, sometimes what we need, even if you cannot do certain kinds of researcher is to begin talking with us and with the program folks about your ideas so that someone else might be able to get up and work on some of, you know, we can work together. There is huge advantage of the system that we have put in for supporting research in women, the practice-based research, the CREATE study, the COINs that are going on. Even I have seen them meet up with researchers and we often can put you in touch with someone who might have similar ideas or similar topic, similar target. Working together, obviously, is one of the things that women seem to do best in the research arena.

Moderator:Thank you very much. I really want to thank you for joining us today, Patty, especially in the middle of a huge storm that we are getting. So, yeah, and I also want to thank all of our attendees for joining us. We had a nice involved audience today. I am going to ask our attendees, please do not log off right now. I am about redirect you to a feedback survey, and we do appreciate your feedback as it is your opinions that help guide which sessions we do have presented. So, once again, thank you so much, Patty, for joining us, and everybody have a great day.

Dr. Hayes:Thank you.

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