**Transcript of Cyberseminar**

**Spotlight on Women’s Health Series**

**What Progress Have We Made on the VA Women’s Health Services Research Agenda?**

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

**April 4, 2013**

**What Progress Have We Made on the VA Women’s Health Services Research Agenda?**

**April 4, 2013**

*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**http://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm**or contact elizabeth.yano@va.gov*

Moderator:As we are getting to the top of the hour, we want to start on time. I am going to go ahead and introduce our speaker today. We have Dr. Becky Yano presenting for us. She is the Director of the VA Greater Los Angeles HSR&D Center of Excellence for the Study of Healthcare Provider Behavior. Also, research – I am sorry, a senior research career scientist and principal investigator for the Women’s Health Research Consortium; and Adjunct Professor of Health Policy and Management at the UCLA School of Public Health. We are very pleased to have Dr. Yano sharing her expertise with us. At this time I am going to turn it over to her.

Elizabeth Yano:Thank you so much, Molly, I appreciate it very much. This is actually consistent with a talk that we have actually provided to the Women’s Health Research Network Steering Committee as well as the Advisory Committee for Veterans. We thought it was important to revisit the progress we have made on the VA Women’s Health Services Research Agenda. 

I deliver this on behalf also of the Women’s Health Research Network. My co-PI, Dr. Susan Frayne; Diane Carney, our PBRN and program manager; Dr. Ruth  Klap, who is the women’s Health Research Consortium program manager; and our important site, founder site leads, Lori Bastian, Anne Sadler, and Bevanne Bean-Mayberry. I am trying to page down. 

Moderator:Just click anywhere on the slide and it just should advance.

Elizabeth Yano:Just as a brief overview, we will be talking about the development of VA Women’s Health Research Agenda. Review progress on the VA Women’s Health Services Research Agenda, which is the subset of that one, including gaps and opportunities for future funding and research development. Provide and then – and then provide an update on the progress of the VA Women’s Health Research Network, including the VA HSR&D funded Women’s Health CREATE.

We wanted to start with a poll questions on what is your primary role in VA.  Are you a student, trainee, or fellow, clinician, researcher, manager, policymaker, or some other category?

Moderator:Thank you, Dr. Yano. The answers are streaming in for our attendees, just simply click the circle next to the answer that best describes your primary role. We have already three-fourths of our audience answers. We will give people just a few more seconds to get their response there. Then we can go over the results. It looks like the answers have stopped streaming in. At this point I am going to close the results. I am sorry, close the poll, and share the results. Dr. Yano, would you like to talk through those real quick.

Elizabeth Yano:Sure. It looks like the majority of our folks today on the phone are researchers, almost 50 percent. We have, one in five are managers or policymakers. About ten percent clinicians and ten percent students, trainees, or fellows; and a group of folks that do not fit one of those categories. But a very good diverse group. This is exactly the kind of audience mix we were hoping for today. Thank you so much.

We have a second poll question, if you want to go ahead, Molly?

Moderator:Sure, pull that up. Sorry, I am actually having a hard time seeing the whole slides. Would you mind reading through it?

Elizabeth Yano:Okay, so I will go ahead and read it. Are you directly involved in women’s Veteran’s care?  Are you a women’s health medical director?  Or a women veterans program manager either at the VISN or facility level?  A women’s health provider other than a – the women’s health medical director, or women’s health staff, or women’s health manager, or policymaker?

Moderator:Thank you. I was having a little technical difficulty there. Alright, it looks like we have had 30 percent of our audience vote. The answers have stopped streaming in. I believe we have gotten the responses that we are going to. I am going to close this out and share it.

Elizabeth Yano:This is very consistent with the kind of research clinical partnerships we really enjoy. That I think have been substantial contributors to the impacts that researchers have been able to have on women’s health research in the VA. As you can see about one quarter of our participants today are women Veteran program managers. About a third are women’s health providers. 

We have a lot of important front line women’s health staff and managers. Thank you so much. Given that half of you are researchers, we know that ability to conduct research while you are also working with women Veterans on the front line. One of the things that contributes quite a lot of richness in the work we do. Thank you very much.

Let me go ahead and get started on the VA Women’s Health Research Agenda. The development of the agenda has spanned now a number of years. There was an agenda setting conference of experts that the Office of Research and Development supported back actually in 2003 with the initiation of the development of this agenda for a conference. Fifty experts in biomedical lab, rehabilitation, clinical sciences, and health services research back in 2004. 

Dr. Donna Washington led development then of the first special issue of the Journal of General Internal Medicine focused on women’s Veterans health and healthcare. Also, funded by HSR&D; and so if you are interested in the original agenda, it is the citation is here. We also in that same issue had some work that was one of the original research clinical partnerships with Maureen Murdoch, as you see here. Arlene Bradley, Carol Turner, and Bob Klein who is in policy and planning to really start to think about women and war. What physicians should know since the Journal of General Internal Medicine goes to general internists across the country.

We began to work more on the integration of women Veterans into the A quality improvement research efforts, especially through QUERI  That first research agenda as I said spanned all of the Office of Research and Development services. We included in infrastructure group; and their recommendations were to build ORD’s capacity through networking, collaboration, and mentoring. Focus requests for proposals to address the methodological limitations and barriers to conducting women’s health research in the VA. To increase the visibility and awareness of the kinds of areas of research that needed to be pursued; and of women’s Veterans health and healthcare concerns. 

They basically said increase the number of PIs. Increase the number of grants. Increase the number of papers and move forward. HSR&D funded actually the rest of the infrastructure for this in 2010 through what is called the Women’s Health Research Network. It has two components, the women’s health research consortium, which I lead; and the Women Veterans Practice Based Research Network that Dr. Susan Frayne at VA Palo Alto leads. Our consortium focuses on cyber seminars such as the one today in partnership with CIDER. A series of workshops, we provide one on one and group technical consultations. Support research and development and grant proposal submissions. We have research collaborations through right now nine work group that are topically focus. We also provide mentorship including identifying appropriate mentors; mentoring teams and content experts and methodological experts; we – and career development award support, and networking. 

We have also now are nearing completion of journal supplements as well, which I will talk about more in a moment. The PBRN started with four founder sites. Provide and promise multi-site technical support including access to expertise in the cooperative studies program at VA Palo Alto. Had a series of internal projects to test the infrastructure. 

Again, I will talk more about that in a moment. The second research agenda was really focused on health services research rather than the other ORD services. Really became a partnership between ORD and HSR&D, which took a very major leadership role in this development as well as benefiting from the Secretary Shinseki's interest in women’s health. That was supported by an agenda setting conference in 2010. A lot of strategic planning; an updated systematic review supported by VA’s Evidence-based Synthesis Program. Then the SDR stands for Service Directed Research projects, which is the Women’s Health Research Network itself. 

There is also with that agenda setting conference, it was an opportunity to partner with leaders in women’s health outside the VA, including the institute of medicine, department of health and human services, the department of defense, labor, and the like, which really helps us set the stage for VA being a leader in this area. The work from that conference was designed to develop and enhance research clinical partnership. Move forward on the women’s health services research agenda, which was published last – now two year ago in this Women’s Health issue of Women’s Veterans Supplement. 

The new agenda really has been focusing in as you can see health services research domain in access and rural health; primary care, and prevention; mental health, post-deployment health; complex, chronic conditions; long-term care and aging; and reproductive health. We are working to use this as our roadmap moving forward. As you can see, there are many moving pieces that we are managing across the Women’s Health Research Network in partnership with HSR&D, and other groups as we move forward. 

I wanted to provide you an idea of where we are with the current VA women’s health research portfolio. This is information from HSR&D through Linda Lipson, who has been the Scientific Program Manager, at the heart of the partnership through HSR&D as well as HSR&D’s leadership. Under Access/Rural Health, you can see that Drs. Frayne and Hamilton are leading one of the CREATE studies on Lost to VA Care on a – looking at the determinants of attrition of women Veterans who are new to VA care. 

Drs. Bastian and Mattocks are evaluating the quality and coordination of women Veterans outsourced care perceptions with one part of their study focusing on this bridge between VA and non-VA use of care. Since women Veterans are more likely to be referred to community for many services. Dr. Taylor in a Women’s Health Services funded operations project evaluating the VA’s Call Center for Women. The Office of Rural Health has funded a number of pilots around women’s health as well. Then Women’s Health Services is funded through I believe a Congressional allocation, a new national women’s Veterans survey that’s going to be focused on barriers to care. 

Under primary care and prevention, we do have a couple of the other CREATE projects, which I will discuss at the end of our talk today. One is the implementation using evidence-based quality improvement methods in a group randomized trial on the women’s health (PACT) that I am leading with Dr. Rubenstein. Drs. Donna Washington and Kristina Cordasco are co-leading the study on a controlled  trial of Tele-Support and education for women’s healthcare in CBOC, a community based outpatient clinic. 

We also have a study on looking at the impacts of VA’s delivery of comprehensive women’s healthcare on the outcomes and quality that women Veterans receive. Again, on the mammography side, Dr. Bastian’s and pragmatics project also will be looking at the quality of mammography care in particular from a prevention perspective and as a model for examining quality indicators for care that’s delivered through fee-based system contracts.

Portfolio and mental health used to be about I would say two-thirds of the original research agenda that would span all of the Office of Research of Development plus focused on women’s mental healthcare. Some of the current studies or recently completed studies include Maureen Murdoch’s Beyond Service Connection – What Helps PTSD Disabled Veterans Get Better?  Sadler’s work on evaluating VA’s assessment of military sexual trauma in Veterans. 

This is – the next one is Lisa Najavits randomized control trial of  women's substance abuse treatment, MBA, and that is a clinical sciences R&D trial. Rachel Kimerling has a Mental Health Services funded study of over 6,000 women Veterans to conduct overall mental health assessments of their needs. Then Sabina Oishi has also recently completed an evaluation of women’s mental health care arrangements in VA also funded through Mental Health Services.

Post-deployment health has actually got quite a substantial group of studies at this point. I think in large part that is probably because of the post-deployment health request for proposals in addition to interest in women health. Cindy Brandt is recently I believe concluded the women’s Veterans cohort study which is among OEF, OIF Veterans. 

There is a – Dr. Desai has a study of gender differences in post-deployment addictive behaviors among returning Veterans to see interest in work in pain of GI origin among women in OEF, OIF. Anne Sadler has begun to do intervention studies for online work to facilitate post-war access of Reserve and National Guard service women to mental health care. There has been a lot of interest in working urogenital symptoms, depression, and PTSD among OEF, OIF women Veterans. 

We also have a series of studies again, some of which have been recently completed. Some of which are still underway at least the papers are still underway. Again another study from Dr. Sadler, who is part of our women’s health and research network and leads the post-deployment health division on combat, sexual assaults, and PTS, post-traumatic stress in OEF, OIF military women. 

Nina Sayer has done work on soldier to civilian, a randomized trial of intervention to promote reintegration. Also of a study of family reintegration among OEF, OIF Veterans. Then Dawne Vogt at the National Center for PTSD in Boston has been looking at stigma, gender, and other barriers to VA use for OEF, OIF Veterans. So has a strong sample of both male and female Veterans in that work. 

Under complex chronic disease, we do not have as many studies as yet. I think there is a lot of room for opportunity here. One is the Cooperative Studies program by – led by Kathy Magruder and Amy Kilbourne on The Long-Term Health Outcomes Of Women In Service During The Vietnam Era. That is I believe over 10,000 of women Veterans. That they are undergoing chart reviews this year and data around this should be available next year. Jennifer Martin, the GLAHS here in greater Los Angeles has been looking at women Veterans with insomnia. 

Donna Washington has been working through studies funded by Women health services to advance screening and referring of women Veterans for homeless vulnerability. I believe she is working on a validation study currently. Then Dr. Kristina Cordasco has been working also with Women Health Services and Emergency Services in VA to conduct the first inventory of the VA emergency services for women Veterans in terms of processes and resources.

Here is one example of the Cooperative Studies program. It is the most comprehensive examination of a group of women, Vietnam era Veterans to date. As I mentioned, it is about 10,000 women selected to participate in this ground breaking study with surveys and interviews complete. They have remarkably high response rates is my understanding to the point where some researchers do not even believe it. Because of the level of engagement that Veterans...  I think many of you who are doing work in this area have noticed at least for survey work that there is substantial interest in women Veterans being able to have a voice and share their experiences in some of these studies. They have done a really wonderful job in this work and they are going through chart abstractions. 

Under reproductive health, Dr. Sonya Borrero has a new HSR&D funded study around contraceptive care in the VA. The other two projects of which I am most familiar are women’s health services funded operations activities developing a state of VA reproductive healthcare report under the Reproductive Health Director, Dr. Laurie Zephyrin; and two fellows who are –  one of which is now a career development awardee, Dr. Hoggatt and Dr. Jodie Katon. Then there has been a whole series of maternity care coordination pilots that Women’s Health Services has funded that a number of health services researchers are involved in even though they are actually operations activities. 

We also have a couple of projects that are funded under what I would call agenda support. Obviously, Women’s Health Research Network, but also the women Veterans health research dates to base. That is under the evidence synthesis program that Dr. Paul Shekelle leads here at VA Greater Los Angeles. This has been the home for both of the systematic reviews thus far that have come out about women Veterans health in broad terms. Supported also, the women’s mental health systematic review done by Mental Health Services; and provide the database searches. 

I wanted to kind of – given that information. Go through and say where really are we – are we with this agenda?  For access and rural health we have some of these studies about – through the women’s health CREATE. Some studies on attrition and youth, but the rest is really funded by women health services or the Office of Rural Health directly through operations and quality improvement initiatives. There is a lot of room for additional growth in this area. Because these increasingly are high priority areas. 

For primary care prevention, I would say the majority of the work here still is within the new CREATE studies that I will talk about in a moment. But again, the rest is Women’s Health Services or directly primary care funded. I think that there is a lot more work that needs to be done in that arena. As I mentioned before, mental health used to be the biggest area with substantial focus on PTSD and military sexual trauma. There has been expansion to substance abuse disorders and medical and mental health co-morbidities. As you will see in a moment, a very increased [inaud.] focus on OEF, OIF Veterans. But also substantial partner funded work in this area as well. 

Now post-deployment health is the biggest area by far in women’s health research. But that still is mostly mental health focused. I could tell you that mental health services is very interested in that continuing expansion of work into areas of depression, and anxiety, perhaps bipolar. Because there is a substantial evidence-based around PTSD and military sexual trauma as a condition, and for which we are trying to make sure we screen and deliver care as needed in follow-up. 

It is not that those areas are not continued to be of interest. But we do not have as much research evidence in the other areas as we might have. In post-deployment health most of that is actually HSR&D funded. Some of that work is moving to interventions now, which I think is a very strong plus. For complex chronic aging, in addition to the cooperative studies program, and the emerging work in insomnia. There is not as much work in that area as we might have. 

As Dr. Frayne has pointed out in the women’s health and evaluation initiative also funded by women’s health services, we really have a trimodal age group now. Where a third – let us say. I am not sure if it is a third. But the third grouping of women that we see in the VA are of – are older. We do not have I think enough research in that area to really gear us up well enough for what we would like to do them. Then there is – most of that work currently is still Women’s Health Services funded. 

The ED work was the women’s health evaluation initiative is and the homeless work currently is. Then a reproductive health other than the contraceptive use study. It is always possible I had missed something in the review of the portfolio on HSR&D and QUERI. Most of that work continues to be emerging. Early pilot work, and we are hoping that people take up the banner and pursue more work in that area as well. 

You wanted to know in what areas of research you actually are interested in?  Or either conducting yourself, or if you are a clinician who is not a researcher. That you are interested in seeing more work done. I think we – I think the poll only gives you a chance to check five of these. I think we have combined two. But I am going to let Molly help with this one.

Moderator:Great, thank you. In what areas of research are you interested?  We did have to combine the first two as we only have five answer options. Access/real health or primary care/prevention, mental health, post-deployment health, complex chronic conditions/long-term care, reproductive health. It looks like we have had about half of our audience vote. But, answers are still streaming in so we will give people just a few more seconds. 

We do appreciate your responses that this does help inform the Women’s Health Research consortium. Alright and the answers have stopped streaming in. We have had about two-thirds of our audience vote. I am going to go ahead and close it, and share the results. You should be able to see those now, Dr. Yano.

Elizabeth Yano:This is good because it looks like people are prepared to focus on these areas and that they map pretty well. I am very pleased to see some of the folks who are interested in some of these more emerging areas where we do not have quite as much research going on now. This is very exciting for us as we move forward. Thank you, Molly.

Moderator:Not a problem.

Elizabeth Yano:Let me talk to you about the Women’s Health Research Network and what WHN has been accomplished so far. We have as you can see in these next set of slides a series of deliverables that we were put forward. Then we will talk about achievements to date. This is again really the group of people that I mentioned earlier in terms of the team of people. We have said yes, we would at least make sure that ten proposals got submitted and four reviews of PBRN. 

Fortunately not just ten were submitted but over 20 research grants have been funded through the support of the Women’s Health Research Network, seven of which are multi-site to use the PBRN. There are more projects coming in all of the time. Hopefully, you have seen or you will see shortly reminder that for the June submission cycle for HSR&D, if you have any interest in working with one or more of the PBRN sites then it is important to contract Dr. Susan Frayne sooner than later because there is  a review process that we undergo. We had promised 30 cyber seminars in three years. We got 30 of them delivered in two. We have anywhere from 100 to 600 participants in each of these with a lot of download activity, a lot of presentations. 

Also, there has been substantial growth in the recognition of the importance of women Veterans research at the highest levels. We have been providing media roundtables both with the with the chief R&D officer, Dr. Joel Kupersmith, and the undersecretary for health where we invited to actually present some of the work that was ongoing. We were posed to identify ten mentors for use in all of you as needed. We identified well over 15 in the first year. 

I am very pleased to say that we have already helped support three career development awardees get HSR&D funding. We have 15 more participating in ongoing CDA seminar series. The three so far are Melissa Dichter who is doing work in intimate partner violence. Kate Iverson, who is also doing work in intimate partner violation. And Katherine Hoggatt, who is looking at substance abuse treatment disorders, treatment patterns and care improvement for women Veterans specifically. We also have been very committed to increasing research partnerships, which many of you know is at the foundation for the movement in HSR&D to do more partner oriented research that hopefully will have greater impact. 

We have helped support the achievement of funding for over 15 projects with VA policy and operations leaders, including an evaluation of CBA Tele-Gynecology, the work that you have probably seen about the sourcebook that really describe the kinds of conditions women Veterans have, their utilization patterns, and the like, and other kinds of activities. The secretary also had a groundbreaking initiative to create a women Veterans task force at the secretary level, which was supported by the Center for Women Veterans. We provided consultation on the agenda. 

Also, direct task force participation and helped draft the national operating plan for evaluation and data collection, including a plea that they actually use this network of researchers and experts in women’s health that all of you represent rather than always sending these things out outside the VA given the tremendous expertise that the VA has in fact developed. We will see how that evolves. But I think that there will be additional partnerships; private, public partnerships moving forward. 

We also provide, as I mentioned before, technical consultations. We said we would do at least 60 a year. We have easily more than a dozen a month. That has been something that is, continues to be a priority for us. I have already mentioned the Women’s Health Services Research conference that started a month or two after we were funded. We have leaders as I said from virtually every VHA office and as well as other departments within the federal government and groups outside the VA as well. That really established the research agenda we talked about. 

Now HSR&D felt so strongly about the support for that kind of collaborative in-person partnered research development and support opportunity that they put forward a conference request for fiscal year ’13. As many of you know, travel constraints have been substantial. However, we are still waiting to hear. We may know in the next  month or two if there is going to be in fact a meeting this summer. The moment we hear anything we will get that information out to everyone as soon as humanly possible. 

We also have nine work groups that are quite active across the country that are led by leaders in key research areas. Currently the ones that we are supporting are in PTSD, military sexual trauma, chronic pain, intimate partner violence, reproductive health, substance abuse disorders, disparities, qualitative research, and LGBT issues. I encourage you to contact Dr. Ruth Klap, she is on MS exchange. If you are interested in joining any of these. Or if there are new topical areas you would like us to focus of moving forward.  

We also said that we would help make sure that at least 20 research articles focus on women Veterans health and, or gender disparities would get published. We did that through two supplements, one to women’s health issues, which had 18 papers from 47 submitted. Commentaries that were also – had been widely cited; four of the papers in that special issue were among the top five cited in the journal for the entire year. When we are currently leading an effort, Dr. Lori Bastian is the lead guest editor for the Journal of Internal Medicine special issue that is coming out soon. Including Hayden Bosworth, Donna Washington, and myself as guest co-editors. We ended up ultimately being able to accept 19 papers. 

But what I want you to notice here is that we had 79 submissions. It is really great, but it also made our task quite difficult. Because there were a lot of very high quality papers that we had to in some cases turn away. But I think that we have got a great special issue that should be coming out in the next couple of months. We also have special editorials in that one with HSR&D, Women’s Health Services, and a PBRN summary. Because the experts in practice based research networks outside the VA have indicated the importance of the effort that Dr. Frayne and others are leading in the VA. 

We also have secured an editorial forum, Dr. Carolyn Clancy, who is the director of the Agency for Healthcare Research And Quality. A distinguished women’s health professor who basically has indicated that her summary is about talking about VA being a forefront of using research to impact improvements in care. Many people have heard this statement before, but more papers would be published in the last five years than in the previous 25 years combined. As far as we can tell, that acceleration appears to be continuing. It has been really gratifying to watch the work that everyone has been putting forward. 

Many of you have probably seen these, but back when we got this work started. This is what the number of women’s health researchers in the VA looked like. When we thought we were kind of a lonely group, if you will. By 2004 for the first research agenda meeting we had about 50. This included the non-health services researchers. By 2010, we had a significant growth. This is what we look like today. I continue to welcome all of your efforts to work forward in this area. To partner with front line clinicians and our managers because we have an alignment of the stars literally and figuratively to really make sure this – the work that we pursue has impact for women Veterans’ experiences in quality of care. 

Now we have over 200 investigators that are VA based in the consortium. This is beyond what our wildest dreams were at the time. But the consortium continues to grow. Our opportunities have an impact to do this as well. The practice based research network as I mentioned under Dr. Susan Frayne’s leadership had projects to test the infrastructure. In the interest of time, I will not go through these in too much detailed. But we do have Dr. Kimerling who led a study to interview women Veterans on – in primary care clinics to understand their mental health conditions in primary care. That study is now concluded. 

There are about 550 women Veterans who are enrolled across the four founder sites in Los Angeles, Palo Alto, Durham, and Iowa City. Dr. Dawne Vogt and Dr. Ellen Yee, who are from Boston and New Mexico, Albuquerque specifically, respectively are doing an implementation research trial taking the caring for women Veterans curriculum for improving provider and staff awareness of gender issues in care delivery and care environments through a cluster randomized trial of evidence-based quality improvement to test how well we can in fact partner with providers and managers on site to do quality improvement trials and implementation science. That has been quite a process, a learning process, and a really important study.

Then Dr. Ruth Klap wanted to test our ability to really work with, and interview, and engage frontline providers. She and her team have completed interviews with VA, primary care women’s health and mental health provides about the frontline quality improvement needs for women Veterans. I think some of that work again has that same theme about making sure that those of us who are researchers are not simply an ivory tower considering what we think is important. But that we continue to engage with women Veterans and with women’s health providers in the VA to make sure that we are aware of the things that they see on a day to day basis so that we can design research to tackle those issues. 

The other thing we promised was that the PBRN would grow to at least six sites. Given a remarkable enthusiasm and welling from the field in terms of interest in participating in women’s health research and quality improvement, we actually now have 37 registered sites that are very geographically dispersed across the United States. In fact, serve about 100,000 women Veterans, and that represents about one in every three women Veterans that are served in VA. This is map of the distribution of the sites currently across the country. The patient populations are quite diverse. 

The site leads expertise as well in terms of content areas of expertise being a combination of researchers and clinicians. We represent 17 of the 21 VISNs in the U.S. Almost two-thirds of these come from sites where there are HSR&D centers. We have already discussed the opportunity to expand the network even further and are in strategic planning to discuss that as we continue to have sites that independently ask for the opportunity to join this network. Let me give you an orientation now to the CREATE. There were ten, I believe ten CREATEs funded by VA HSR&D. 

We are one of those and our focus is on using research to accelerate implementation of comprehensive women’s healthcare in VHA. What are the CREATE?  As everyone on the phone probably knows the VA is pretty outstanding when it comes to we will say high on the scale of acronym users. CREATE stands for Collaborative Research to Enhance and Advance Transformation and Excellence. It is a VA HSR&D initiative to promote partner oriented research to increase the impacts of research on Veterans care. Each of these was designed to be a group of three to five coordinated projects in a focused area that we were supposed to capitalize on national expertise. 

This was not supposed to be just based in Los Angeles, or just based in Houston, or just based in some other location. That we were really reaching out to get the best people to run projects that would fit together in a meaningful way. That we were also pressed to make sure we had meaningful engagements of VA program leaders, perhaps at the VISN level, but also VA Central Office with a demonstrated commitment on their part to act on the findings. I think that is a critical part of what the CREATE was designed to accomplish. It was a highly competitive national process and review. Fortunately the women’s health CREATE was among those that were ultimately funded. 

Our goal, as I mentioned before is to accelerate implementation of comprehensive care for women Veterans. That is codified in VHA handbook 1330.01, which many of you – those of you who were involved in women’s healthcare are probably intimately familiar with. But there are two pieces of it that we focused on. One is that each VA must ensure that eligible women Veterans have access to comprehensive medical care, including care for gender specific conditions and mental health conditions comparable to care providers for men. 

Then the second part that drove our design of studies that all enrolled women Veterans need to receive comprehensive primary care from a designated women’s health provider who is interested and proficient in the delivery of comprehensive primary care to women irrespective of where they are seen. I think that is an essential piece to what the handbook is also moving forward, that women should not be having to travel vast distances to get comparable care that men get in a single location. I have alluded to these projects before, but I wanted to just go through them one more time. 

Project one is led by Susan Frayne at Palo Alto and Alison Hamilton, who is an anthropologist here in Los Angeles. They will be doing secondary analysis of large VA databases as well as qualitative interviews of women Veterans who do and do not use the VA to really help us better understand what is happening with the 30 odd percent of women who are new to VA care who have not returned in two years. 

Hopefully they are healthy and doing well. But we do not know if that is in fact the case. The second project I lead with my colleagues Ann Chou and Danielle Rose is on Impact of VA Delivery of Comprehensive Women’s Healthcare. This is for those of you familiar with my research very consistent with the kind of work we have historically. 

But we will be capitalizing on site visits and interviews we conducted in the last couple of years and in concert with the Watch Data, which is an organizational assessment tool that the Women’s Health Services program has been fielding each year to design a new survey of care arrangements and the details for primary care, specialty care, mental health care. How care arrangements are set up differently, if at all, or women Veterans?  Making sure we really understand how comprehensive care – what it means on the ground. Then link those to quality and utilization measures so that we better understand further improvements that may be necessary. 

The third project is a group randomized trial of evidence-based quality improvement approaches. Building on what we have learned from our past demonstration last year in VISN 22 to help local practices adapt past features to the needs of women Veterans and their locale. We currently have four VISNs we are working with in this project. 

The fourth one I mentioned before is what is called a stepped wedge trial, it is a VISN 22 focus of tele-support in education including e-consults and a women’s focused scan eco set of activities to help make sure that designated women’s health providers in community based outpatient clinics are able to deliver care without having to necessarily forward women on up to the main medical center as often as probably happens currently. 

Then the fifth project is another one of these multiple PI projects where it has a combination of interviews led by Dr. Kristin Mattocks on women Veteran – women Veteran interviews for those who have received care outside the VA that is paid for by the VA. Interviews of community based providers and VA providers who do the referring as well as fee basis managers who choose where these women may end up having the opportunity to go get care outside the VA. To really understand the barriers of facilitators, of the quality perceptions and the coordination that does or does not happen for women Veterans. 

Then Dr. Bastian will be leading a chart review study to really evaluate the quality of some of the services that in fact are delivered. All of these are groundbreaking. This one is really the first evaluation ever of the care that is happening outside the VA. We are very excited about it. As I mentioned, these CREATEs have to be partnered. Our partner is not surprisingly for the overarching creator, Dr. Patricia Hayes, who is the chief consultant for Women’s Health Services. As well as Dr. Susan McCutcheon who is head of Women’s Mental Health in the Office of Mental Health Services. 

Each of these projects also have project specific partners in the office of primary care, Dr. Gordon Schectman, Dr. Richard Stark, and Joanne Shear in the Office of Primary Care for the Women’s Health PACT work. Then the Office of Specialty Care Services is related to the work in SCAN-ECHO, and Dr. Washington and Cordasco’s study. The VHA Purchase Care and the National Radiology Office are very interested in the fee basis and outsourced care study; and are directly involved in that work. Then VISN 22 is where at least two of these studies are focused currently, although others will be standing four, six, and eight different VISNs. We are establishing a women’s Veteran CREATE council. We are in the only early stages of that. 

But again, we want to be committed to making sure that we have integrated and thought about, and are attendant to women, the Veterans voices in the work that we conduct. All of these studies, even though I think the initial applications to be considered for a CREATE were now two years ago, and it was quite a gauntlet, if I may so. The projects are now all IRB approved and are launching; and launched actually last month. I just wanted to mention two more things I think are on my list here. Then it will open up for questions and answers. That is I want to make sure everyone is familiar with the research to practice pipeline. 

That inside and outside the VA, the notion is, is that we move from basic and biomedical research through translational studies to clinical science and knowledge to make sure that we are figuring out ways to apply what we learned through research to healthcare  delivery procedures, and new medications, and new surgeries, and the like. That health services research then moves on to look from efficacy to effectiveness. How we actually changed delivery systems, care models and configurations to implementation research that was really about now that we know something works, how do we in fact get an entire healthcare system to adopt it, implement it, spread it, and sustain it. Historically, that has been through a variety of health services interventions, practice guidelines, diagnosing gaps in care. 

Then testing implementation strategies. The dilemma has been that there has been what you might call a voltage drop in the actual changes in routine care both for processes and outcomes despite the impacts of an individual research study may show. When we think about implementation it is often that the lack of a handoff to our managers and clinicians on the front lines. We bring our published manuscripts. They go great. That does not give me a roadmap for what to do on the frontline. We do the best we can to pull people through that pipeline. 

I think the Women’s Health Research Network at this point is hoping to accelerate intervention, implementation, and impact through the Consortium by adding some tools to help pull all of you through this pipeline. That the PBRN is helping on the ground partnership, enabling multi-site research in ways that we have not been able to do before. That the CREATE should help us find new pathways to partnered research that creates new ways to improve this flow. If we are lucky, then we really will see additional changes in routine care, both in practice, and policy, and outcomes for the Veterans we serve. 

I wanted to thank you for your time and attention. We have lots of different resources for you. We welcome your contacting us as needed. We are open now for questions.

Moderator:Thank you very much, Dr. Yano. For those of you that joined us after the top of the hour, we – to submit your question or comment, simply type it in to the GoToWebinar dashboard that is on the right-hand side of your screen. Just type it into the box and press send. While we go through the Q&A, I do want to put up another slide. Give me just one second. But we will start with a question real quick. Do the workgroup collaborations involve non-VA researchers as well?

Elizabeth Yano:That is a really good question. Most of them actually do. We at first, or really I should say I had some concerns about making sure that the extensive collaboration culture in the VA would be respected by groups outside the VA. So far, we have found the integration of non-VA experts to be a really strong advantage. I think our collaborative culture has been adapted very quickly, adopted by others. So far, it has actually been a real strength. Yes, we do in fact have non-VA experts in some of these workgroups.

Moderator:Great, thank you for that answer. Our next question, hold on one second here. Sorry, we have got so many to go through. Who is being targeted to serve on the CREATE councils?  Also, who is the point person for finding out more information about the councils?  

Elizabeth Yano:A really good question; currently, the main contacts for the CREATE council are either myself. Just elizabeth dot yano at va dot gov. since right now, Ruth Klap’s e-mail is up on the screen. You are welcome to e-mail her as well if that is easier. We also have a CREATE liaison, Angela Cohen. She is angela dot cohen2 at va dot gov who is working with me across all of the CREATE studies. I think in terms of membership, we are working with Dr. Hayes’s office. We are trying to make sure that it is clear what our main purposes are in this particular council, it will be more strategic than tactical on the ground knowledge. I am very interested in making sure that we have representatives from different periods of service. Different kinds of experience with and without VA care. We are still putting together the criteria and the plan for putting that together. But I am happy to hear people’s ideas. Please feel free to e-mail me.

Moderator:Thank you , the next question; who is being targeted to serve on the...?    I am sorry. Are you involved with the million Veteran research?

Elizabeth Yano:The million Veteran program, we are indeed familiar with and in fact here at VA Greater LA, we have one of the few practicing clinical geneticists who has also got health services research training, Dr. Marin Scheuner. She is familiar also with the Million Veteran program. We have, through the PBRN under Dr. Frayne’s leadership, I think done some contacts with them to make sure that they are having a reasonable set of hits and enrollment among women to make sure women are adequately represented in the million Veteran program. To my knowledge, currently they actually are doing reasonably well with their recruitments. We do not have an active collaboration with them. But they are aware of us as a resource. I hope that answers your question.

Moderator:Thank you. They can always write in for further clarification if they would like. The next question – do the workgroup collaborations involve non-VA researchers as well?

Elizabeth Yano:Yes, they do. They do. I think I answered one like that just a moment ago.

Moderator:Thank you. What is your opinion of the most critical and under addressed areas for research in women’s health.

Elizabeth Yano:That is a very good question. I think that the slide that I described that goes by the roadmap questions, the access and rural health and the like reflect my considerations for where I think more work needs to be done. We know remarkably little about reproductive health needs or care delivery patterns. How care is organized. The outcomes of care for reproductive health in the VA. It is, I would say a pretty solid black box. 

I think that I know Mental Health Services is very interested in more research in areas in a more comprehensive framework around mental health. PTSD and military sexual trauma related research continues to be important. But more work in some of these other areas. I think that it – the field is wide open to be looking at care for older women Veterans. We have – I think that I would also refer people to the fact – to the Women’s Health Services Research Agenda. 

I mean, if you want me to say is what I think the most important one is. It is really difficult. Because there is such a community of researchers here. Such a substantial need that it is honestly hard for me to come up with a single most important area. As a researcher myself, my own biases is probably around the vital importance of helping women access gender sensitive comprehensive care in a focused way. Reduced, making sure that their experiences from the moment they walk into the place to the moment they leave are all appropriate, gender sensitive, high quality. 

It is really about equitable access to high quality of care. There is a lot of different strategies to accomplish that. I – in my view we could have all 200 plus people in the Consortium be well funded and find a way to broker different aspects of this work such that we do not actually overlap but add value and richness to the portrait and the profile of what we can do to help improve – continually improve care for women Veterans. 

I know I did not totally answer the question. But for me, it is a philosophy and an action oriented agenda that is going to require many hands on deck.

Moderator:Thank you very much. While we are waiting for more questions to come in, I just wanted to let you know that several people have written in saying this was an excellent talk. They very much appreciate you addressing the field. Also, several people are wondering is there so much great information in the slides?  How can we get them?  If you refer back to your reminder e-mail you received about four hours ago, just scroll down. 

There is a direct hyperlink to slides. You can always e-mail cyber seminar at va dot gov, and we will be happy to send you a set. It looks like no more questions have come in. Would you like to give any concluding comments, Dr. Yano?

Elizabeth Yano:Happy to do so. I thank everyone for their participation today. We are in the Consortium in the network. Extremely interested in always better understanding the kinds of problems that all of you think we should be attending to, that we can help identify other researchers within and outside the VA to focus on areas. We continue to provide technical consultations. But I worry sometimes that we might be the best secret in town despite our cyber seminars and the like. 

Please do realize that you can contact us for support. Sometimes that contact means that we identify some other expert in the country. We have really put together some wonderful collaborations that are supporting people’s advancement. We are here to help. We do have a wonderful team that continues to grow all the time. I would encourage you to take advantage. I also want to make sure that everyone recognizes the tremendous leadership of HSR&D service and QUERI in this kind of work even with the first research agenda effort. 

HSR&D was tapped to oversee the development of the research agenda. We have been tremendously fortunate for both the support through the service directed research project, but also just the level of participation of our steering committee and the like. This has definitely been a community of work. We are also applying for the development of yet another Women’s Health Research Journal supplement. 

Keep that in mind as people are developing their work. Again, we would be interested in other workgroups that you think need to be put together as we move forward. Let us know how best we can communicate to you. Make sure that you have access to this kind of support that you need. Thank you very much.

Moderator:Great, thank you, Dr. Yano. It is always such a pleasure to have you present for us. I would like to encourage our attendees to visit the cyber seminar page you can find in the archive catalogue past women’s health sessions that have taken place, and in the registration catalogue, you can find future ones that you can sign up for. 

I also want to echo Dr. Yano’s thanks for joining us today. We do appreciate your attendance. As you exit today’s session, there is a brief survey that will pop up on your screen. Please do take the time to just fill out those five or six questions as your opinion is what helps us set up our program. Thank you very much everybody for joining us today. Enjoy the rest of your day. Thank you.

[END OF TAPE] 

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