Background: Women in V

Women• Play an increasing role in military and veteran 

representing:

– 20% of new recruits recruits– 17% of reserve and guard forces– 15% of active d t u y forces

 Represent one of the fastest growing groups 

healthcare users

Center for the Study of Healthcare Provider Behavior 
Why Do A Systematic Systematic Revie

Revie

• Women’s military experiences & responses to their ex

often unknown or distinct from men

• The i t mpac of those experiences on h lth ea st t a us and 

needs is important for care delivery

• Systematic Systematic reviews reviews of research research evidence evidence can inform he

decisions made by managers and policymakers

• 5 years ago, 1st ever synthesis of the scientific literatu

veterans veterans’ health was conducted conducted (Goldzweig (Goldzweig et al 2006

• Since then, rapid expansion of WH research occurred 

Center for the Study of Healthcare Provider Behavior 
Objectives

• To systematically assess the recent lite

on women veterans’ health and categ

literature into key themes

• To identify gaps in the recent literatur

addressed by future research and poliefforts

Center for the Study of Healthcare Provider Behavior 
Methods

• Searched multiple scientific databases

– MEDLINE, Psy , chINFO, World Cat– search terms women and veterans

• Expert VA and DOD Contacts

Center for the Study of Healthcare Provider Behavior 
Methods

• Title screen of all articles by team conse

• Full screen of articles articles by 2 WH physicia

physicia

set criteria

• Each arti l c e summari d ze using stand d ar 

form and categorized into evidence tab

Center for the Study of Healthcare Provider Behavior 
Methods: Screening Crite

Study meets criterion A, plus B, or C, or D: 

A) Study relates to US veterans or military

B) Study includes women veterans, compares men 

and women, or analyzes women separately

C) Study involves active duty military females and involv

health condition or functional status that requires medical int

D) Topic is relevant to VA healthcare or 

how VA care is delivered to women 

Center for the Study of Healthcare Provider Behavior 
Literature Search

VA & DOD Experts

675

Articles Collected

Collected At T

At T

380

Articles Screened

Us 

195

Articles Assessed*

Center for the Study of Healthcare Provider Behavior *This count does not include Goldzweig et al. 
Acceleration of Women Veteran Literat

Time

JGIM Special Issue 2006 JGIM Special Issue 2006

contributed to the increase

More articles were identified 

in 2004-2008 than in the 

previous 25 years years

Center for the Study of Healthcare Provider Behavior 
Women Veteran Literature Characterist

Funding

A ti l R i d Articles Reviewed 1978-2004 (N 182) 2004 (N=182) 2004Type of Study- Observational 147( ) 81% - Descriptive 22(12%) - Qualitative 7(4%) - Systematic Review 4(2%) - Experimental 2(1%) Type of Funding*- VA 82(45%) -DOD n/a 

*not mutually exclusive

Center for the Study of Healthcare Provider Behavior 
Key Areas in Published

Women Veteran Literature

Category 

Depy py lo ment and Post Deployment Health 

Organizational Research Quality of Care and Patient Satisfaction Quality of Care and Patient Satisfaction Access to Care and Utilization Psychiatric Conditions Psychiatric Conditions 

*Not mutually exclusive

Center for the Study of Healthcare Provider Behavior 
Results: Deployment Hea

S bj t A Subject Area K Fi di Key Findings

Reproductive Health Reproductive problems were common a

deployed OEF/OIF women

Frequent issues included pregnancy, UTor pap smear abnormalitiesPregnant women with deployed partners Pregnant women with deployed partners 

duty or with >1 child had higher stress le

Center for the Study of Healthcare Provider Behavior 
Results: Deployment Hea

S bj t A Subject Area K Fi di Key Findings:

Mental Health High rates of +PTSD screens and MH sy

Compared to men women returning from Compared to men, women returning from 

more likely to screen positiveAssault history prior to combat doubled r

onset PTSD symptoms in women and monset PTSD symptoms in women and mMultiple deployments contribute to + MH Psychiatric evacuations from combat thecommon; women were overrepresentedSocial support appeared protective for w

Center for the Study of Healthcare Provider Behavior 
Results: Organizational Rese

Key Findings:

• Presence of a gynecologist in VA or a separate gyn

women’s cli i n c is associtd a e with

‐ IUD availability‐ ad d vance gynecol i og c procedures

‐ emergency gynecology services after hours

• Organizational culture and l h eadership had positive 

– Practice environment for MST* providers

– Presence of separate WH clinic in primary care

Center for the Study of Healthcare Provider Behavior 

*MST – Military Sexual Trauma
Results: Quality of Care

Key Findings:

• Satisfaction ‐ outpatient satisfaction impacted by a

f l ema e providers, gynecology care, women’s cli i n c

• Quality of care measures are similar to men, but a

control, HTN control control, and immunization immunization

• CV disorders more common among women vetera

to civilian women

• Urological problems are common and hormonal co

needs are high in military military women

Center for the Study of Healthcare Provider Behavior 
Results: Quality Quality of Care co

Key Findings:

• Pharmacy ‐ inappropriate prescriptions are are equ

in VA vs. non‐VA, b t u women in VA are more lik l e y 

such meds

• Surgery Surgery ‐ surgical surgical morbidity morbidity and mortality mortality outcome

outcome

or lower in VA vs. non‐VA for women

• CV outcomes outcomes ‐ limited limited data on how to improve improve car

women in VA

Center for the Study of Healthcare Provider Behavior 
Results: Access & Utilizat

Utilizat

Key Findings:• Limited access or use was associated knowledge gap

care and incorrect incorrect information information

• Dual use (VA & non‐VA care) was lower

– when gynecology care or women’s clinics were p

– among Medicare Medicare eligible eligible veteran veteran women vs. me

• Women with positive positive screens screens for MH disorders disorders, trau

diagnoses tend to use more healthcare services tha

without positive MH screens or men veterans

Center for the Study of Healthcare Provider Behavior

p
Results: Psychiatric Condit

Key Findings:

• Support strong association between PTSD and MST

• Negative health effects from both conditions for b

and men

• Women with trauma history report anxiety for inva

and male providers

Center for the Study of Healthcare Provider Behavior 
Results: Psychiatric Condition

Condition

Key Findings:

• PTSD related stress impacts veteran families includ

marriage, parenting, and other adj t t us ments

• A few studies show soci l a support may be a factor 

and quality of life among

• Women veterans

• Children of women veterans• While in military, pregnant, or after they transition h

Center for the Study of Healthcare Provider Behavior 
Building Knowledge Knowledge Prior ....Prior 

• Research gaps indicated limited knowled

• Prevalence of chronic diseases• Preferences & self reported needs

• Utilization patterns within/outside VA

• Transitions from military to veteran status

• Quality of care women vets receive, and methods s

to improve quality

Source: Goldzweig et al 2006

Center for the Study of Healthcare Provider Behavior 
Building Knowledge Knowledge Advan

....Advan

• Treatment outcomes in PTSD:

– Schnurr (2007) study is first multi‐centered, randomized coo

focused on outcomes outcomes in women

– Prolonged exposure therapy gave better outcomes than sta

– Showed clinical outcomes studies on women veterans are f

• Access to Care

– We know much more about barriers, perceptions, and utiliz

than ever b f e ore for b ld ui ing a f d oun ation to interventions

• Organizational Determinants of Quality

– We understand nderstand more abo t u how care is organi ed organized, feat res features 

women, and impact of strong leadership for support of care 

Center for the Study of Healthcare Provider Behavior 
Ongoing Gaps Future ...Future VA Rese

Rese

• Clinical and intervention outcome studies

– for chronic mental health & physical conditions

• Health issues for women across the life span (pregna

• General care or gender differences for veterans with 

or traumatic b i ra n i j n ury

• Challenges or strategies for co‐managing mental hea

general preventive health

• Transitions from military to civilian life• I t mpac of military d t u y, t iti ransitions and h lth ea outco

military/veteran families

Center for the Study of Healthcare Provider Behavior 
Limitations

• Possible missing articles on women ve

• Search terms may not have been spec

spec

research on a population subgroup

• Publi i cat on bias

Center for the Study of Healthcare Provider Behavior 
Summary

• Number of articles in current review (5 yrs) su

number retrieved from prior 25 yrs

• Growth of studies likely due to increased VA s

• Most research research remains remains observational, observational, but

– Documents clear shift from descriptive to analytic

access, utilization, q y ualit and post‐dep y lo ment h

– Demonstrates 5 clinical trials– Provides an evidence base for detecting barriers, 

delivery, and to begin to identify best practices

Center for the Study of Healthcare Provider Behavior 
Implications

• Areas more f ll u y dl d eve oped in women veterans’ re

should serve as a foundation for future interventio

implementation research in VA

• Substantial knowledge on women veterans’ menta

issues should expand

– To include studies on treatment modalities and outcome– To explore explore ways in which veteran veteran, provider provider or practice practice se

se

incorporate evidenced based treatments & evaluate out

Center for the Study of Healthcare Provider Behavior 
Online Database

• T l oo for researchers and cli i i n c ans

• Companion to the written report

• Structured abstracts in searchable format

• Currently updated through Bean‐Mayberry 

report

• Goldzweig et al. to be added

• Regular update searches to keep database 

Center for the Study of Healthcare Provider Behavior 
Online Database

http://web3.rand.org/women_vets

Center for the Study of Healthcare Provider Behavior 
Online Database

http://web3.rand.org/women_vets

Center for the Study of Healthcare Provider Behavior 
Online Database

http://web3.rand.org/women_vets

Center for the Study of Healthcare Provider Behavior 
Online Database

http://web3.rand.org/women_vets

Center for the Study of Healthcare Provider Behavior 
Online Database

http://web3.rand.org/women_vets

Center for the Study of Healthcare Provider Behavior 
VA Women s Women’s Health Link

• VA Women’s Health Systematic Review

http://www.hsrd.research.va.gov/publicatioomens‐health.pdf

• VA Women s Women’s Health Database Database

http://www.hsrd.research.va.gov/for_reseamens health/search cfm mens_health/search.cfm

• VA Evidence Synthesis Program

htt // h d h / bli ti http://www.hsrd.research.va.gov/publicatio

Center for the Study of Healthcare Provider Behavior 
WH Synthesis Team

• Fatma Batuman MD• Bevanne Bean‐Mayberry MD, MHS• Caroline Goldzweig MD, MSPH

• Christine Huang MD

• Isomi Miake‐Lye BA

• Paul Shekelle MD, PhD

• Donna Washington MD, MPH

• Elizabeth Yano PhD, MSPH

Center for the Study of Healthcare Provider Behavior 
Thank you

• VA Greater Los Angeles Evidence Synthesis Program & 

California/RAND Evidence‐based Practice Center

• VA G t rea er Los A l nge es HSR&D C t en er St ff a

• For assistance with standardized abstracts

• VA Health Services Services Research Research &Development &Development Service Service, 

DC

• Women Veterans Veterans Health Strategic Strategic Healthcare Healthcare Group 

Washington, DC

• VA Center for Information Information Dissemination Dissemination and Educati

Educati

(CIDER)

• The Upperman & Bean‐Mayberry Family

Center for the Study of Healthcare Provider Behavior

pp y y y